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 the Necessity for the Hospitalization of: , Respondent. Date of Birth: ) ) ) ) ) ) )

Case No. PETITION FOR INITIATION OF INVOLUNTARY COMMITMENT

, petitioner alleges that the respondent is mentally ill and as a result of that condition is gravely disabled or presents a likelihood of causing serious harm to himself/herself or others. Petitioner respectfully requests the court to conduct or to arrange for a screening investigation of the respondent as provided in AS 47.30.700. If this investigation results in a determination that the respondent is mentally ill and as a result of that condition is gravely disabled or presents a likelihood of causing serious harm to himself/herself or others, the petitioner requests that the court issue an ex parte order for temporary custody and detention for emergency examination or treatment. Respondent was taken into emergency custody by under AS 47.30.705. The Peace Officer/Mental Health Professional Application for Examination is attached. Petitioner respectfully requests that the court issue an ex parte order authorizing hospitalization for an evaluation as provided for in AS 47.30.710. Facts in support of this request are as follows: 1. The respondent named above is , Alaska. years of age and resides at

2.

I know or am related to the respondent as follows:

3.

Are there any other pending cases involving the respondent? describe and provide case numbers.

If so, please

4.

The facts which make the respondent a person in need of (a screening investigation) (hospitalization for evaluation) are:

Page 1 of 2 MC-100 (9/08)(st.3) PETITION FOR INITIATION OF INVOLUNTARY COMMITMENT

AS 47.30.700

Case No. 5. Persons having personal knowledge of these facts are (include addresses):

Date

Petitioner's Signature Type or Print Name Petitioner's Address Petitioner's Phone Verification

Petitioner says on oath or affirms that petitioner has read this petition and believes all statements made in the petition are true. Subscribed and sworn to or affirmed before me at Alaska on . (date) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: ,

(SEAL)

A person acting in good faith upon either actual knowledge or reliable information who makes application for evaluation or treatment of another person under AS 47.30.70047.30.915 is not subject to civil or criminal liability. [AS 47.30.815(a)] A person who willfully initiates an involuntary commitment procedure under AS 47.30.700 without having good cause to believe that the other person is suffering from a mental illness and as a result is gravely disabled or likely to cause serious harm to self or others, is guilty of a felony. [AS 47.30.815(c)] I certify that on a copy of this petition was sent to:

Clerk:
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AS 47.30.700