IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of: Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER: FOR INVOLUNTARY HOSPITALIZATION DUE TO NONCOMPLIANCE WITH VOLUNTARY TREATMENT AGREEMENT [W.Va. Code: §27-5-2(h)] This matter was heard on the __________ day of ___________________________, ________. The movant in this cause, [month] [year] _________________________________________, appeared in person [Check Appropriate Items] pro se, or was represented by ___________________________________________________. The Respondent appeared in person and by appointed counsel, __________________________________________________. Testimony was also presented by ________________________ representing ______________________________________________, the treatment provider, and also by the following witnesses: __________________________________________________________________________________________________________. After hearing the testimony of witnesses and receiving all relevant evidence; upon the arguments of counsel for the parties, the Court makes the following FINDINGS: 1. The Respondent has failed or refused to comply with the terms and conditions of the Voluntary Treatment Agreement in the following manner: [detail findings where Respondent has either failed or refused to comply with the agreement, referencing parts of the agreement and the dates of noncompliance, if applicable] __________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _________________________________________ [attach additional pages as necessary] C CL MH08 INV 19; SCA-MH 907F / 8-08 VTA INVOLUNTARY HOSPITALIZATION ORDER Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com 2. The Respondent remains: [check applicable finding(s)] __________ Addicted and because of such mental illness likely to cause serious harm to him/her self and/or others. __________ Mentally Ill and because of such mental illness likely to cause serious harm to him/her self and/or others. 3. And further, the Court finds that the current address of the Respondent is _________________________________ _______________________________________________________________________________________________________, and the date of birth of the Respondent is ___________________________________________________________. 4. Additional findings: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________________________________________________. Accordingly, it is hereby ORDERED: 1. That the Respondent, __________________________________________________, be committed to the custody of the Secretary of the Department of Health and Human Resources for initial placement at ________________________________ _____________________________________________ mental health facility; and 2. That the Respondent be further examined and/or treated as required under the provisions of West Virginia Code: § 27-5-3. The Respondent is hereby remanded to the custody of the Sheriff of this County who shall transport the Respondent to the mental health facility as required by law. And further, if applicable [Initial if applicable] ___________ It is ORDERED pursuant to West Virginia Code: § 27-5-3(g) that the Respondent shall be involuntarily hospitalized for addiction only until detoxification is accomplished. And further, if applicable [Initial if applicable] ___________ It is recommended that the Respondent be closely monitored for possible medical complications pursuant to West Virginia Code: § 27-5-2(i). C CL MH08 INV 19; SCA-MH 907F / 8-08 VTA INVOLUNTARY HOSPITALIZATION ORDER Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com And further, pursuant to West Virginia Code § 61-7-7(a)(4), Respondent is hereby notified that all individuals who have been involuntarily committed to a mental institution in West Virginia are required to immediately surrender any firearms in their ownership or possession. Upon consideration of the testimony available at the probable cause hearing in this matter, it is further determined that the appropriate public or private individual or entity to act as a temporary conservator of such firearm property to be immediately surrendered by Respondent is ______________________________________________________________________, until such time as this matter may be more fully heard by the Circuit Court of this County. The Clerk shall enter the foregoing ORDER as of the day and date first above written and shall transmit three attested copies thereof to the Sheriff of this County, one for delivery with the Respondent to the mental health facility. The Clerk shall also transmit attested copies to all counsel of record, the Movant named above, the Respondent, and to the _____________________________ ________________________________ Mental Health Center. ____________________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE / MAGISTRATE C CL MH08 INV 19; SCA-MH 907F / 8-08 VTA INVOLUNTARY HOSPITALIZATION ORDER Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com