IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER: PROBABLE CAUSE FOR INVOLUNTARY HOSPITALIZATION FOR EXAMINATION [W.Va. Code: §27-5-2(f) 27-5-1(d), & 27-5-4(p)] This matter was heard on the _________ day of ____________________________, _________. The Applicant in this cause, [month] [year] _________________________________________, 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 or Physician’s Assistant, and also by the following witnesses: ______________________________________________________________ ___________________________________________________________________________________________________________. After hearing the testimony of witnesses, receiving all relevant evidence, examination of the written report and certification of the Examiner, and hearing the arguments of counsel for the parties, the Court makes the following FINDINGS: [Initial Appropriate Items] __________ The Respondent is a resident of ___________________________ County, West Virginia. __________ The Respondent was 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. 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 such mental illness or addiction if allowed to remain at liberty. C CL MH08 INV 13; SCA-MH 906 /8-08 PROBABLE CAUSE ORDER Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com The specific facts upon which these findings of probable cause are based are as follows: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ And further, the Court finds that the current address of the Respondent is ________________________________________ _______________________________________________________________________________________________________, and the date of birth of the Respondent is ___________________________________________________________. 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 13; SCA-MH 906 /8-08 PROBABLE CAUSE ORDER Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com And further, if applicable [Initial if applicable] __________ The Respondent is a NON-RESIDENT of the State of West Virginia. The Clerk is thereby directed to immediately transmit an attested copy of this Order to the Secretary of the Department of Health and Human Resources pursuant to the provisions of West Virginia Code § 27-5-4(p). The Secretary of the Department of Health and Human Resources, or his or her designee, shall make appropriate arrangement for transfer of the Respondent to the State of the Respondent’s residence, stated herein, which shall be conditioned upon the agreement of the Respondent except as qualified by the interstate compact on mental health. 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 counsel of record, to the Respondent, to the Applicant, and to the ______________________________________ ______________________________________________________ Mental Health Center. ____________________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE / MAGISTRATE C CL MH08 INV 13; SCA-MH 906 /8-08 PROBABLE CAUSE ORDER Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com