IN THE CIRCUIT COURT OF __________________ COUNTY, WEST IN RE: ___________________________________________________ [Name of Licensed Independent Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification] Address: __________________________________________ __________________________________________ Phone #: _______________________________ Case No. ____________-P______________ REPORT/REQUEST OF COURT AUTHORIZED EXAMINER REGARDING LICENSING OR CERTIFICATION CHANGE [W.Va. Code: §27-5-2(e)] On this _______ day of ____________________, 2_____, comes the above named Licensed Independent Clinical Social Worker (WV SW License # ____________________) or Advanced Nurse Practitioner with Psychiatric Certification (WV RN License # ____________________) and advises the Court per prior Order of the following: [check appropriate box(es)] ‘ Examiner's license is no longer in good standing with the West Virginia Board of Social Work Examiners. ‘ Examiner’s license and/or certification is not longer in good standing with the West Virginia Board of Examiners for Registered Professional Nurses. ‘ Examiner’s certification as a _____________________________ from the agency, _____________________________ is not longer in good standing: ‘ Examiner reports the following additional certifications/licenses: [describe/name and provide certification/licensee number(s) and expirations dates] ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ________________________________________________________________________________________ ‘ Examiner became subject to the following disciplinary action related to his/her license: [add additional pages if needed] ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ _______________________________________________________________________________________ C CL MH07 EXAM 4 American LegalNet, Inc. www.FormsWorkFlow.com ‘ Examiner requests “ continuation “ discontinuation “ removal of limitation [check appropriate box] of authorization to perform examinations for probable cause proceedings for involuntary hospitalization. ‘ Examiner submits the following additional information for the Court’s consideration: [add additional pages as needed] ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________ VERIFICATION I, ______________________________________________________________________, Examiner/Petitioner, after making an oath or affirmation to tell the truth, certify, UNDER PENALTIES OF FALSE SWEARING as provided by law, that the information and statements contained in this Report and any additional pages added hereto are true and accurate to the best of my knowledge, information and belief, that any and all attached copies are true and accurate copies of the originals. I understand that if I knowingly provide FALSE information, I could be subject to a criminal charge of false swearing. _______________________________ Date _____________________________________________ Signature The foregoing was sworn to or affirmed before me on the ______________ day of ______________________, 2______. ____________________________________________________________________ Notary Public My commission expires: __________________________________________________________ SCA-MH 924R / 6-06 REPORT Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com