IN THE CIRCUIT COURT OF THE THIRTEENTH JUDICIAL, CIRCUIT
IN AND FOR HILLSBOROUGH COUNTY, FLORIDA
MENTAL HEALTH DIVISION


In RE:

CASE No:__________________________

DIVISION: Z

Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination


I/We , being duly sworn, am filing this sworn statement requesting a court order for the involuntary examination of , hereinafter referred to as PERSON. This petition and affidavit will be included in the PERSON'S clinical record and may be viewed by the PERSON.

I understand that by filling out this form, the PERSON may be taken by law enforcement to a mental health facility for an examination. I SWEAR that the answers to the following questions are given honestly, in good faith, and to the best of my knowledge.

1. a. I live at: (Print your full address and phone number)

Street Address:

City:State:

Phone Number:()-

b. I work as a :

Work Address:

City:State:

Phone Number:()-

c. The PERSON lives at, or may be found at, the following addresses:

Street Address:City:

Street Address:City:

Street Address:City:

I have the following relationship with the PERSON:

3. (Check the one box that applies)

[] a. I or a family member have, or have not previously made allegations to law enforcement involving this person on such as domestic violence, trespassing, battery, child abuse or neglect, Baker Act, neighborhood disputes, etc. as described:


[] b. This person has, or has not previously made allegations to law enforcement about me or my family on
such as domestic violence, trespassing, battery, child abuse or neglect, Baker Act, etc. as described:


4. (Check the one box that applies)
a. I or a family member are not now, and have not in the past, been involved in a court case with the PERSON.
b. I or a family member am now, or was, involved in a court case with the PERSON. This case is/was a
in in
Explain:

5. I am on good terms with the PERSON at the present time. (Check one box) Yes No
If you checked no, please explain:

6. I have known the PERSON for (how long).
a. The PERSON has only recently displayed unusual kinds of behavior.
b. The PERSON has, over a period of time, always acted in a strange manner.
c. The PERSON's behavior has developed over a period of time.


COMPLETE THE FOLLOWING ONLY IF THE
SECTION APPLIES TO THIS CASE:

7. I have seen the following behavior, which causes me to believe that there is a good chance that the PERSON will cause serious bodily harm to himself/herself or others:

On
at approximately I saw the PERSON:

8. Other similar behavior I have personally seen is as follows:

9.To my knowledge or belief,I doI do not believe these actions were a result of retardation, developmental disability,
intoxication, or conditions resulting from antisocial behavior or substance abuse impairment.

CHECK AND/OR ANSWER APPLICABLE SECTIONS

10. a. I have attempted to get the PERSON to agree to seek assistance for a mental or emotional problem(s). I explained the purpose of the examination (describe when, who was present, and whether you or another person explained the need for the examination):

b. I did not try to get the PERSON to agree to a voluntary examination because:

c. The PERSON refused a voluntary examination because:

Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination


11. The following steps were taken to get the PERSON to go to a hospital for mental health care:

These steps did not work because:

12. I believe that the PERSON is unable to determine for himself/herself, why the examination is necessary because:

13. I believe that the PERSON has a mental illness which will keep the PERSON from being able to meet the ordinary demands of living because:
14. I believe that without care or treatment, the PERSON is likely to suffer from neglect or refuse to care for himself/ herself, because:
15. I believe that this lack of care or neglect will lead to the PERSON hurting himself or herself because:

16. Can family or close friends now provide enough care to avoid harm to the PERSON?
YesNo, If not, why?

Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination

Provide the following identifying information about the person (if known) if it is determined necessary to take the person into custody for examination:

County of Residence: Age:

Sex: Male Female Race:

Height: Weight: Hair Color: Eye Color:

Does the PERSON have access to any weapons?NoYes

Is the PERSON violent now?NoYes Has the person been violent in the recent past?NoYes

Does the PERSON have any pending criminal charges against him/her?NoYes

GUARDIANSHIP:

1) Does the PERSON have a legal guardian?NoYes

2) Is there a pending petition to determine the PERSON's capacity and for the appointment of a guardian?
NoYes
If YES to either of the above, provide the name, address and phone number of the current or proposed guardian.
Name: Phone Number:()-
Address:
PHYSICIAN: Phone Number:()-

MEDICATIONS:

CASE MANAGEMENT:


I understand that this sworn statement is given under oath and will be treated as though it was made before a judge in a court of law. I understand that any information in this sworn statement which is not to the best of my knowledge and done in good faith may expose me to a penalty for perjury and other possible penalties under the statutes of the State of Florida. Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.
Signature of Affiant/Petitioner: ________________________________________________

SWORN TO AND SUBSCRIBED before me OR SWORN TO AND SUBSCRIBED before me
this __________ day of ________________________, Day Month Year Day Month Year by _____________________________________ who is personally known to me or presented ________________________________ as identification. ________________________________________________ Notary Public - State of Florida My Commission expires: Date_____________________

OR:

SWORN TO AND SUBSCRIBED before me OR SWORN TO AND SUBSCRIBED before me
this __________ day of ________________________, ______________ Clerk of Circuit Court _____________________________ County, Florida By: _______________________________________________________ Deputy Clerk

A copy of the petition(s) must be attached to an Ex Parte Order for Involuntary Examination and accompany the person to the nearest receiving facility.

Instructions:
Fill out all applicable sections
Print the form
Bring the form to the Hillsborough County Couthouse