Free Petition to Set Hearing to Determine Involuntary Participation of Treatment of Hospitalized Person - Kentucky

AOC-735 Rev. 7-02 Page 1 of 1

Doc. Code: PHDIT
01/9/2007 11:49 am Ver. 1.01

Case No. PETITION TO SET HEARING TO DETERMINE INVOLUNTARY PARTICIPATION OF TREATMENT OF
HOSPITALIZED PERSON

Court County

District

Commonwealth of Kentucky Court of Justice www.kycourts.net KRS 202A.196; 202B IN THE INTEREST OF: Name: Address:

1.

COMES PETITIONER, (name) _________________________________________________________________, and states he/she is a: [ ] [ ] Qualified Mental Health Professional Qualified Mental Retardation Professional

employed at __________________________________________________________________________________ located at _____________________________________________ , ________________________________________ Street City ___________________________________ , Kentucky. 2. 3. 4. PETITIONER states he/she believes Respondent, a current patient/resident at said Hospital/Facility, should be ordered to accept treatment as prescribed by his/her Treating Physician. PETITIONER states Respondent has refused to accept or participate in a Treatment Program individualized for his/her needs. PETITIONER states a Review Committee met with Respondent and his/her [ ] Counsel [ ] other Representative,

(Name) ____________________________________________________________________________________, and concluded Respondent's prescribed Treatment Plan was appropriate; necessary to protect himself/herself or others from harm; the proposed treatment is the least restrictive alternative mode of treatment presently available; and the treatment prescribed would reasonably benefit him/her. 5. 6. PETITIONER further states Respondent has had the gains and risks of the proposed Treatment Plan explained to him/her, and his/her [ ] Counsel or [ ] other Representative. THEREFORE, Petitioner prays a de novo Determination Hearing be set within seven (7) days to determine if Respondent should be ordered to participate in his/her prescribed Treatment Plan. ___________________, 2_____. ____________________________________________ Signature of Petitioner

Date:

Subscribed and sworn to before me this _______ day of _______________, 2_____. My Commission expires: _________________________, 2_____. _____________________________________________ Notary Public _____________________________________________ County, Kentucky

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