Code Section Group

In the Superior Court of the State of California
For the County of____

The People

For the Best Interest and Protection of

⎫
⎪
⎪

as a

⎪

and Concerning

and

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⎪

Petition

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_____ Respondents

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⎭

_______, residing at ______ (tel. _______), being duly sworn deposes and says: That there is now in the county in the City or Town of __________

a person named ______, who resides at ______, and who is believed to be a ______. That the person is ____ years of age; that __ the person is ____ (sex) and that __ the person is ____ (single, married, widowed, or divorced); and that ____ occupation is ____.

That the facts because of which petitioner believes that the person is a ____ are as follows: That __ the person, at _______ in the county, on the____ day of ____, 20__,

That petitioner’s interest in and case is

That petitioner believes that said person is ____ as defined in Section ____.

That the persons responsible for the care, support, and maintenance of the ____, and their relationship to the person are, so far as known to the petitioner, as follows:

(Give names, addresses, and relationship of persons named as respondents)

Wherefore, petitioner prays that examination be made to determine the state of the mental health of ____, alleged to be ____, and that such measures be taken for the best interest and protection of said ____, in respect to the person’s supervision, care and treatment, as may be necessary and provided by law.

_____ Petitioner

Subscribed and sworn to before me this ____ day of ______, 20__.

________________________________, Clerk of the Court
By _____________________________________________ Deputy

The People

For the Best Interest and Protection of

⎫
⎪
⎪

Order
for
Exammination
or
Dentention

as a

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and Concerning

and

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⎪

⎪

_____ Respondents

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⎭

The People of the State of California

_____ (peace officer) _____

The petition for ________ having been presented this day to me, a Judge of the Superior Court in and for the County of ________, State of California, from which it appears that there is now in this county, at ________, a person by the name of ________, who is a ________.

And it satisfactorily appears to me that said person is sufficiently ________ that examination should be made and hearing held, if demanded, to determine the supervision, treatment, care or restraint, if any, necessary for his best interest and protection, and the protection of the people.

I do hereby appoint ________ and ________ as medical examiners to make a personal examination of ________, the person alleged to be ________, and to report thereon to the court, pursuant to Section ________ of the Welfare and Institutions Code.

* Now, therefore, you are commanded to notify said ________, to submit to an examination ________ on or before the ________ day of ________, that thereafter he may be taken before a judge of the superior court in this county for examination and hearing to determine the measures to be taken for the best interest and protection of said ________, as a ________, as provided by law.

* And it affirmatively appearing to me that said person is sufficiently ________ that he is likely to injure himself or others if not immediately hospitalized or detained, you are therefore commanded to forthwith detain said ________, or cause him to be detained for examination and hearing, pending the further order of the judge, at ________, and there becared for in a humane manner as a ________ and provided with any medical treatment deemed necessary to his physical well-being.

* And it satisfactorily appearing to me that said person has failed or has refused to appear for examination when notified by order of this court, you are therefore commanded to forthwith detain said ________ or cause him to be detained for examination and hearing, pending the further order of the judge, at ________, and there be cared for in a humane manner as a ________.

I hereby direct that a copy of this order, together with a copy of the said petition be delivered to said person and his representative, if any, at the time of his notification; and I further direct that this order may be served at any hour of the night.

Witness my hand, this ________ day of ________, 19__.

_____ _____ Judge of the Superior Court

* Strike out when not applicable.

Return of Order

I hereby certify that I received the above order for examination or detention, and on the ________ day of ________, 19__, served it by notifying and delivering to said ________ personally, and to his representatives, if any, to wit, ________, a copy of the order and of the petition, *or by apprehending said person and causing h__ to be detained for examination and hearing and for humane care as an alleged ________ at ________; until further ordered and directed by the judge.

* I hereby certify that prior to the service of the above order for detention and the apprehension of ________ I served notice on the person and his representative, if any, as required under Article 2 (commencing with Section 5200) of Chapter 2 of Part 1 of Division 5 of the Welfare and Institutions Code.

Dated __________, 19__.

_____ _____ Signature of officer

* Strike out when not applicable.

In the Superior Court of the State of California
for the County of ________

The People

For the Best Interest and Protection of

,

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⎪
⎪
⎪

Certificate
of Medical
Examiners

as a and

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⎪

Concerning ,

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and ,

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_____ Respondents

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⎭

We, Dr. ________ and Dr. ________, medical examiners in the County of ________, duly appointed and certified as such, do hereby certify under our hands that we have examined ________, alleged to be a ________, and have attended before a judge of said court at the hearing on the petition concerning said person, and have heard the testimony of all witnesses, and, as a result of the examination, have testified under oath before the court to the following facts concerning the alleged ____________:

Name  

Address  

Age Sex  

Occupation Marital status  

(Single, married, widowed, divorced) 

Religious belief  

Pertinent case history  

General physical condition  

Present mental status  

Laboratory reports (if any)   

Tentative diagnosis of mental health  

Recommendation for disposition or supervision, treatment and care  

Reason for the recommendation  

Date ________________

_____ _____ Medical Examiner

_____ _____ Medical Examiner

In the Superior Court of the State of California
For the County of ____

The People

For the Best Interest and Protection of

⎫
⎪
⎪

Order for Care,
Hospitalization,
or Commitment

as a ,

⎪

⎪

and Concerning

and

⎬
⎪

, Respondents

⎪

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The petition dated ________, alleging that ________, having been presented to this court on the ________ day of ________, 20__, and an order of detention issued thereon by a judge of the superior court of this county, and a return of the said order:

And it further appearing that the provisions of Sections 6250 to 6254, inclusive, of the Welfare and Institutions Code have been complied with;

And it further appearing that Dr. ________ and Dr. ________, two regularly appointed and qualified medical examiners of this county, have made a personal examination of the alleged ________, and have made and signed the certificate of the medical examiners, which certificate is attached hereto and made a part hereof;

Now therefore, after examination and certificate made as aforesaid, the court is satisfied and believes that ________ is a ________ and is so ________.

It is ordered, adjudged, and decreed:

That ________ is a ________ and that _he

* (a) Be cared for and detained in ________, a county psychiatric hospital, a community mental health service, or a licensed hospital for the care of persons with mental health disorders until the further order of the court, or

* (b) Be cared for at ________, until the further order of the court, or

  * (c) Be committed to the State Department of State Hospitals for placement in a state hospital, or

  * (d) Be committed to a facility of the Department of Veterans Affairs or other agency of the United States, to wit: ________ at ________.

It is further ordered and directed that ________ of this county, take, convey, and deliver ________ to the proper authorities of the hospital or establishment designated herein to be cared for as provided by law.

Dated this ________ day of ________, 20__.

_____ _____ Judge of the Superior Court

* Strike out when not applicable.