IN THE CIRCUIT COURT OF __________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER: GRANTING APPLICATION FOR INSTITUTION OF FINAL COMMITMENT PROCEEDINGS [W.Va. Code: §§27-5-3, 27-4-3(c), and 27-5-4] Pursuant to West Virginia Code: §§ 27-5-4 and either 27-5-3 or 27-4-3(c), _______________________________________, Chief Medical Officer of ________________________________________________ mental health facility, has made application to this Court for the institution of final commitment proceedings for the Respondent. The Court has reviewed the application and FINDS it meets the requirements of West Virginia Code: §§ 27-5-4 and either 27-5-3 or 27-4-3(c). Accordingly, it is ORDERED: 1. That a hearing on this application be held on the __________ day of ______________________________, 20______, at the hour of _________M. at [location] ________________________________________________________________________ ________________________________________________, or as soon thereafter as counsel may be heard. 2. That the Clerk of the Circuit Court give notice of this hearing as required by West Virginia Code: § 27-5-4(e) and to the Sheriff of _____________________________________________ County, West Virginia. 3. That _________________________________________ is hereby appointed to examine the Respondent prior to said hearing and to report the results of the examination thereof to this Court at said Hearing. [SEE: West Virginia Code: § 27-5-4(f).] 4. In the event that Respondent has not retained an attorney or cannot afford an attorney, it is further ORDERED that ____________________________________________, is hereby appointed as the Respondent's attorney and further that the Clerk of the Circuit Court shall inform the Respondent of said attorney's name, address and telephone number. It is further ORDERED that the Sheriff of ______________________________________ County shall transport the Respondent to any examinations and hearings ordered and conducted in this cause ENTERED, this _________ day of ______________________, 20___. ________________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE SCA-MH 909 / 6-06 American LegalNet, Inc. www.FormsWorkflow.com