IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of: Case No. ________- MH -________ _____________________________________________, Respondent ORDER: FOR DETENTION, EXAMINATION AND PROBABLE CAUSE HEARING [FOR HEARING TO BE HELD FORTHWITH - W.Va. Code: §27-5-2(e)] On the ______ day of ________________, _______, came the Applicant, _______________________________________, and [month] [year] made application to this Court to order that the above-named Respondent be taken into custody and detained for the purposes of examination and a probable cause hearing pursuant to the provisions of West Virginia Code: § 27-5-2. This Court FINDS the application sets forth facts which are sufficient to meet the requirements for detention, custody, examination and hearing as provided by West Virginia Code: § 27-5-2. Accordingly, it is ORDERED that the Sheriff of ___________________________ County shall forthwith take into custody, detain, and thereafter bring the Respondent before this Court for the purpose of conducting a probable cause hearing forthwith. The hearing shall be held forthwith at the following location _________________________________________________________________________________________ on the _______ day of _____________________, _______, as soon as possible at or about the hour of _____________o'clock _______.M. [month] [year] It is further ORDERED that the attorney named below is appointed as counsel to represent the Respondent in this matter. NAME OF APPOINTED ATTORNEY: ______________________________________________________________________________ ATTORNEY'S ADDRESS: ________________________________________________________________________________________ ________________________________________________________________________________________ ATTORNEY'S TELEPHONE NUMBER (_________) __________________________________________________________________ It is further ORDERED that the __________________________________________ Mental Health Center shall provide or arrange for an examination of the Respondent by a physician, psychologist, or court authorized licensed clinical social worker or advanced nurse practioner, as required by law prior to the probable cause hearing and report thereon to the Court at the probable cause hearing. Should the examination reveal that the Respondent is NEITHER addicted nor mentally ill, or is NOT likely to cause serious harm to self or others because of mental illness or addiction, it is further ORDERED that the examiner shall immediately provide the mental hygiene commissioner, circuit court judge, or magistrate signatory to this Order the results of the examination on a completed Form INV 10 / Form 904 Certificate of Licensed Examiner. [See: West Virginia Code: § 27-5-2(e).] [If applicable, FAX number to which completed form may be sent to presiding judicial officer: (_______)____________________________ .] The Clerk shall deliver attested copies of this order to the Sheriff of ________________________ County, to ________________________________________________ Mental Health Center, to the appointed attorney named above, to the Applicant, and to the Prosecuting Attorney of ________________________________ County, West Virginia for determination of whether it is in the public interest to appear at the probable cause hearing. _____________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE / MAGISTRATE C CL MH07 INV4; SCA-MH 903CCF / 8-08 FORTHWITH CUSTODY ORDER Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com