IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT PROBABLE CAUSE ORDER: FOR RELEASE TO OUTPATIENT TREATMENT PURSUANT TO VOLUNTARY TREATMENT AGREEMENT [W.Va. Code: §§ 27-5-2(f) and 27-5-2(h)] This matter was heard on the __________ day of ___________________________, ________. The Applicant in this cause, [month] [year] _______________________________________, appeared in person [check appropriate item] 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, ___________________________________________________________, the examining Physician/ Psychologist/Court approved Licensed Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification or Physician’s Assistant. Testimony was also heard from [list 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 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. C CL MH08 INV 15; SCA-MH 907 / 8-08 VOLUNTARY TREATMENT AGREEMENT ORDER Page 1 of 4 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 his or her mental illness or addiction if allowed to remain at liberty. The specific facts upon which these findings of probable cause are based are as follows: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Further, the Court finds that the current address of the Respondent is ___________________________________________ _____________________________________________________________________________________________________, and the date of birth of the Respondent is _______________________________________________________. Notwithstanding the foregoing findings of probable cause, the undersigned further FINDS that the Respondent's circumstances make him/her amenable to outpatient treatment in a nonresidential or nonhospital setting pursuant to a Voluntary Treatment Agreement beginning on the ______ day of _______________, _______, based upon the following: [state the evidence [month] [year] presented, or other basis, in support of this finding] _______________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ The undersigned further FINDS that appropriate outpatient treatment is available, to-wit:_____________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ C CL MH08 INV 15; SCA-MH 907 / 8-08 VOLUNTARY TREATMENT AGREEMENT ORDER Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ The undersigned has also reviewed the Voluntary Treatment Agreement submitted by Respondent, dated the __________day of _______________________, ______, does hereby approve the same, a copy of which is attached hereto and made a part hereof, [month] [year] the contents of which are hereby incorporated herein by reference. Therefore, the undersigned hereby ORDERS that the Respondent shall be: [initial appropriate finding] ________ involuntarily committed to the custody of the Secretary of the Department of Health and Human Resources for initial placement at ___________________________________________________ mental health facility until the effective date of the Voluntary Treatment Agreement; further examined and/or treated as required under the provisions of West Virginia Code § 27-5-3 until the effective date of the Voluntary Treatment Agreement; and upon the effective date of the Voluntary Treatment Agreement conditionally released to outpatient treatment upon the terms and conditions set forth in the Voluntary Treatment Agreement. Discharge or release of the Respondent pursuant to the provisions of West Virginia Code §§ 27-7-1, et. seq., and/or § 27-5-3, during the involuntary inpatient commitment period set forth hereinabove and prior to conditional release upon the Voluntary Treatment Agreement shall supersede this provision for release upon the Voluntary Treatment Agreement. 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. _________ conditionally released to outpatient treatment upon the terms and conditions set forth in the Voluntary Treatment Agreement. This ORDER and the incorporated Voluntary Treatment Agreement shall remain in effect for [insert applicable time period] ____________________________________________________________, which time period is [initial applicable time period]: ___________ Not more than six (6) months, inasmuch as the court hereby finds that the Respondent has not been involuntarily committed in the past two years. (continued next page) C CL MH08 INV 15; SCA-MH 907 / 8-08 VOLUNTARY TREATMENT AGREEMENT ORDER Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com ___________ Not more than two (2) years, since the court hereby finds that the Respondent has been involuntarily committed in the past two years, to-wit: [insert date and place of last involuntary commitment] ________ __________________________________________________________________________________ The Clerk shall enter the foregoing ORDER as of the day and date first above written and shall transmit attested copies thereof, together with the voluntary treatment agreement attached hereto, to the Applicant, the Respondent, to all counsel of record, the Secretary of the Department of Health and Human Resources and to ________________________________________________ Mental Health Center. ______________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE / MAGISTRATE C CL MH08 INV 15; SCA-MH 907 / 8-08 VOLUNTARY TREATMENT AGREEMENT ORDER Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com