Free Petition and Declaration Regarding Capacity to Give Informed Consent to Medication (Riese Petition) - California

(RIESE) MEDICATION CAPACITY PETITION (TYPE/PRINT) Hospital:______________________________ (Name) Unit:__________________________________ (Name or Number) Interpreter Required: NO YES ______________ (Language) SUPERIOR COURT OF THE STATE OF CALIFORNIA FOR THE COUNTY OF LOS ANGELES

In the Matter Of

) ) )

(RIESE PETITION) PETITION AND DECLARATION REGARDING CAPACITY TO GIVE INFORMED CONSENT TO MEDICATION

(Patient's Name)

)

Petitioner, _________________________________________________ declares that: (Please type/print Treating Physician Name) 1. On ___________________ I evaluated ___________________________________ (Date) (Patient's Name) at____________________________________________________________. (Hospital Name) 2. This patient is currently being held at the above facility under Welfare and Institutions Code Section(s):5150(72 hour hold)[ ], 5250(14 day hold) [ ], 5260(additional 14 day hold)[ ], 5270.15(additional intensive treatment 30 day hold)[ ], 5300,(180 day post certification)[ ]. 3. This patient is presently showing symptoms of a mental disorder known as _____________________________________________________________________________ These symptoms are:__________________________________________________________ _____________________________________________________________________________

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4. In my professional judgment the patient would benefit from the administration of the following psychiatric medications: ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. 5. I declare further that I have explained or attempted to explain to the patient the risks, benefits, possible side effects and treatment alternatives as described in Welfare and Institutions Code Section 5213(b) and to obtain the patient's consent to receive medication: (Insert dates and description of each explanation or attempted explanation and the dates these were charted) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________. 6. The patient's response to these efforts was the following: (Verbatim, if possible) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. 7. It is my professional opinion that the patient is not able to give informed consent to the recommended medication because: A) The patient [ ] is aware [ ] is not aware of his/her mental disorder (Explain) ______________________________________________________________________________

B) The patient [ ] is able [ ] is not able to understand the risks or benefits of medication or alternative treatments, (Explain) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. C) The patient [ ] is able [ ] is not able rationally to understand and evaluate information regarding informed consent, and otherwise participate in the treatment decision, (Explain) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. 8. Medication must be administered in order to alleviate the acuteness of the patient's current symptomatology. 9. It is alleged on information and belief that the patient is required to have an advocate/legal counsel appointed and is unable to retain such services. WHEREFORE, Petitioner prays that: 1. An advocate be appointed to represent the patient in the medication capacity hearing. The advocate may be an attorney privately retained by the patient or an employee of the Los Angeles County Department of Mental Health attached to the Patient's Rights Office; 2. The Court issue an order finding that the patient is incapable of giving informed consent during the patient's commitment under aforementioned applicable Welfare and Institutions Code Sections. 3. For all other further and proper relief.

I DECLARE THE FOREGOING TO BE TRUE UNDER PENALTY OF PERJURY AND THAT THIS DECLARATION IS EXECUTED AT , THIS (CITY) (DAY) OF , 19 (MONTH) (YEAR) // Excluding the date the petition is faxed, I am available to present at the hearing at the hospital as follows: Day:_________ Date:_______ Time:________

Day:_________

Date:_______ Time:________

Day:_________

Date:_______ Time:________

(Hearings are held on, Monday, Tuesday, Wednesday, or Friday between 9:30 a.m. and 3:30 p.m. and Thursday, between 2:30 p.m. and 3:30 p.m.) Respectfully submitted, ` By ______________________________ (Treating Physician) // // // // // // NOTICE UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE SERVED A COPY OF THIS CAPACITY PETITION OR NOTICE OF THE FILING OF THIS CAPACITY PETITION TO THE ABOVE NAMED PATIENT

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By___________________________________ (Person designated by the hospital to serve the patient)

_______________ (Date)