Free IN THE SUPERIOR COURT FOR THE STATE OF ALASKA - Alaska

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of: ) ) ) ) ) ) )

A minor under 18 years of age Date of birth:

CASE NO.

DL

REQUEST TO AUTHORIZE PLACEMENT IN SECURE RESIDENTIAL PSYCHIATRIC TREATMENT CENTER The Division of Juvenile Justice at the Department of Health and Social Services requests that the above-named minor who was committed to the custody of the Department on , be placed in a secure residential psychiatric treatment center pursuant to AS 47.12.255. This request is supported by the attached sworn affidavit or sworn testimony of a qualified mental health professional as defined in AS 47.12.990 and AS 47.30.915. The minor opposes this request. The minor does not oppose this request. (date) Approved by Probation Supervisor
I certify that on a copy of this document was sent to: DA Minor's Attorney Parent/Guardian Other: By:

Probation Officer

ORDER The Request to Authorize Placement in Secure Residential Psychiatric Treatment Center is hereby granted denied. It is further ordered that

Recommended on:

Effective Date:

Superior Court Master Type or Print Name

Superior Court Judge Type or Print Name

Date

a copy of this document was sent to: I certify that on DA IO/PO/Placement Facility Minor's Attorney Parent or Guardian Clerk:
DL-165 (5/09)(cs) REQUEST TO AUTHORIZE PLACEMENT IN SECURE RESIDENTIAL PSYCHIATRIC TREATMENT CENTER

Other: