Free Microsoft Word - MC-115 Petition for 90-day Commitment _12-87_ - 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 90-DAY COMMITMENT

As a mental health professional who has examined the respondent, the petitioner alleges that: 1. The respondent is mentally ill and as a result is likely to cause harm to himself/herself or others. gravely disabled as previously alleged in the Petition for 30-Day Commitment. 2. The respondent: continues to be gravely disabled and there is reason to believe that the respondent's mental condition could be improved by a continued course of treatment. has attempted to inflict or has inflicted serious bodily harm upon himself/herself or another since his/her acceptance for evaluation. was committed initially as a result of conduct in which he/she attempted or inflicted serious bodily harm upon himself/herself or another. demonstrates a current intent to carry out plans of serious harm to himself/herself or another. 3. 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 received appropriate and adequate care and treatment during his/her 30-day commitment. The respondent has been advised of the need for, but has not accepted, voluntary treatment.

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The petitioner respectfully requests the court to commit the respondent to the abovenamed treatment facility for not more than 90 days.
Page 1 of 2 MC-115 (12/87)(st.3) PETITION FOR 90-DAY COMMITMENT AS 47.30.740

Case No. The facts and specific behavior of the respondent supporting the above allegations are:

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 of Professional Person In Charge or that Person's Professional Designee Print Name and Title 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) ,

(SEAL)

Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires:
AS 47.30.740

Page 2 of 2 MC-115 (12/87)(st.3) PETITION FOR 90-DAY COMMITMENT