IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER: MOTION TO CANCEL OR MODIFY VOLUNTARY TREATMENT AGREEMENT [W.Va. Code: §27-5-2(h)] This matter was heard on the __________ day of ___________________________, 20________, the Respondent appearing in person and by appointed counsel, ___________________________________________________________. The following also appeared in person: ___________________________________________________________________________________________ ___________________________________________________________________________________________________________ ________________________________________________________________________________________________. Testimony was received from ________________________________________________________ Mental Health Center / Treatment Provider by its representative _____________________________________________ and also from the following individual(s): ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ After hearing the testimony of witnesses and receiving all relevant evidence; upon the arguments of counsel, the Court makes the following FINDINGS: _____________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _____________________________________[attach additional pages as necessary.] SCA-MH 907J-1 / 6-06 ORDER DECIDING MOTION TO CANCEL OR MODIFY Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Accordingly, and based upon the foregoing findings, it is hereby ORDERED that the Respondent's Motion to Cancel or Modify the Voluntary Treatment Agreement is, and the same is hereby: [initial appropriate relief] _________________ Cancellation granted for the reasons set forth below. These proceedings are hereby dismissed. _________________ Modification granted for the reasons contained below. _________________ Denied. The original Treatment Agreement shall remain in full force and effect according to its terms. If this Order grants modification of the Voluntary Treatment Agreement, the same is hereby modified in the following respects: [insert changes to agreement] ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________ If cancellation is granted, the reasons are as follows: _________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________ The Clerk shall enter the foregoing ORDER as of the day and date first above written and shall transmit attested copies thereof to the Respondent, Applicant, all counsel of record, and to the ___________________________________________________ Mental Health Center/Treatment Provider. ____________________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE /MAGISTRATE SCA-MH 907J-1 / 6-06 ORDER DECIDING MOTION TO CANCEL OR MODIFY Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com