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. NOTICE OF VOLUNTARY ADMISSION

The respondent named above was voluntarily admitted for treatment on ____________________, 20____, at ______________________________________________________________________. The respondent was first admitted for evaluation or treatment on __________________________, 20_____, at _________ ____.m.

Date

Signature

Printed Name

Title

Distribution: Original to court Copy to facility

MC-415 (3/01)(st.2) NOTICE OF VOLUNTARY ADMISSION

AS 47.30.725(b)