IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of: ________________________________________, RESPONDENT Date: _____________ Applicant: _______________________________ Case No. _______- MH - ________ ORDER / NOTICE: DENIAL OF APPLICATION FOR INVOLUNTARY CUSTODY FOR MENTAL HEALTH EXAMINATION [W.Va. Code: §27-5-2] It is hereby ORDERED that the application submitted in this matter is DENIED. The basis for such denial is [initial appropriate reason(s)]: __________ The application is unreadable. __________ There is no allegation the Respondent is addicted or mentally ill. __________ Insufficient facts alleged supporting the claim the Respondent is addicted or mentally ill. __________ There is no allegation the Respondent is likely to cause serious harm to him/her self and/or others. __________ Insufficient facts alleged supporting the claim the Respondent is likely to cause serious harm to self and/or others. __________ The Respondent is not a resident of, nor was Respondent found in, ___________________ County, West Virginia. __________ Answers to the following numbered questions in the application are incomplete and require additional information: __________ Other reason(s): _______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________________________________ This denial means the application, as presented, is not legally sufficient under the provisions of W.Va. Code: § 27-5-2. You may contact the Office of the Prosecuting Attorney of __________________________ County should you need advice or assistance. The Court or Clerk is not permitted to provide legal advice. The Mental Hygiene Commissioner, Judge or Magistrate signing this Order is not permitted to discuss this denial or the case with you. The ___________________________________________________________ MENTAL HEALTH CENTER provides 24hour emergency crisis intervention services which may help in this case. You should contact that facility for further assistance if you still believe there is a serious mental health or addiction problem which requires attention. ________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE / MAGISTRATE A copy of this ORDER / NOTICE has been delivered to the Applicant by: _________________________________________________ CLERK / COMMISSIONER / JUDGE / MAGISTRATE SCA-MH 902 / 6-06 DENIAL ORDER Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com