IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -______ ___________________________________ RESPONDENT ORDER: NO PROBABLE CAUSE FOR INVOLUNTARY HOSPITALIZATION FOR EXAMINATION [W.Va. Code: §27-5-2(f)] This matter was heard on the ________ day of ___________________________, 20________. The Applicant in this cause, ___________________________________________, appeared in person [Check Appropriate Items]  pro se, or  was represented by ____________________________________________, Assistant/Prosecuting Attorney of ___________________ County, West Virginia; The Respondent appeared in person and by appointed counsel, ___________________________________; Testimony was also presented by ____________________________________________________________________________, Physician/Psychologist/Court approved Licensed Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification, and also by the following witnesses: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________. After hearing the testimony of witnesses and receiving all relevant evidence, and upon examination of the written report and certification of the Examiner, and the arguments of counsel for the parties, the Court makes the following FINDINGS [Initial Appropriate Items]: The Respondent _________IS _________IS NOT The Respondent _________WAS _________WAS NOT a resident of ______________________ County, West Virginia. found in __________________________ County, West Virginia. ____________ The Respondent is not a resident of the State of West Virginia but is a resident of the State of __________________. The Court further FINDS that there is [Initial Appropriate Items]: __________ PROBABLE CAUSE __________ NO PROBABLE CAUSE to believe the Respondent is addicted. __________ PROBABLE CAUSE __________ NO PROBABLE CAUSE to believe the Respondent is mentally ill. SCA-MH 905-1 / 6-06 NO PROBABLE CAUSE ORDER Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com The Court further FINDS probable cause to believe that the Respondent [initial one] __________IS __________ IS NOT likely to cause serious harm to him/her self and/or others because of mental illness or addiction if allowed to remain at liberty. If all conditions precedent to involuntary hospitalization have been met, this case, nevertheless, is hereby DISMISSED for the following reasons: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________________________________________________. Accordingly, it is hereby ORDERED that the application filed in this matter by the above-named Applicant be, and the same is hereby DISMISSED and the Respondent is hereby released from custody. The following additional matters are noted in the granting of this dismissal: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________________________________________________. The Clerk shall enter the foregoing ORDER as of the day and date first above written and shall transmit copies thereof to counsel of record, the Applicant, and to the ____________________________________________________ Mental Health Center. __________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE / MAGISTRATE SCA-MH 905-1 / 6-06 NO PROBABLE CAUSE ORDER Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com