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. ) ) ) ) ) )

Case No. PETITION FOR 30-DAY COMMITMENT

As mental health professionals who have examined the respondent, the petitioners allege that: 1. The respondent is mentally ill and as a result is likely to cause harm to himself/herself or others. gravely disabled and there is reason to believe that the respondent's mental condition could be improved by the course of treatment sought. 2. The evaluation staff has considered, but has not found, any less restrictive alternatives available that would adequately protect the respondent or others. is an appropriate treatment facility for the respondent's condition and has agreed to accept the respondent. The respondent has been advised of the need for, but has not accepted, voluntary treatment.

3.

4.

The petitioners respectfully request the court to commit the respondent to the abovenamed treatment facility for not more than 30 days. The facts and specific behavior of the respondent supporting the above allegations are:

Page 1 of 2 MC-110 (12/87)(st.5) PETITION FOR 30-DAY COMMITMENT

AS 47.30.730

Case No.

The following persons are prospective witnesses, some or all of whom will be asked to testify in favor of the commitment of the respondent at the hearing:

Date

Signature Printed Name Title

Date

Signature Printed Name Title

Note: This petition must be signed by two mental health professionals who have examined the respondent, one of whom is a physician. AS 47.30.730(a).

Page 2 of 2 MC-110 (12/87)(st.5) PETITION FOR 30-DAY COMMITMENT

AS 47.30.730