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 Involuntary Substance Abuse Assessment and Stabilization


I/We , being duly sworn, am filing this sworn statement requesting a court order for the involuntary examination of , hereinafter referred to as PERSON.

Is the PERSON 18 years of age or older? [] Yes, or [] No. Age of 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 hospital or licensed substance abuse facility for assessment and stabilizaiton. 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. The PERSON lives at, or may be found at, the following address(es):

Street Address:City:

Street Address:City:

Street Address:City:

2. I have the following relationship with the PERSON:

3. I am on good terms with the PERSON at the present time (check one box). []Yes, or [] No. If "no" please explain:

4. (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:


5. (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:

6. I have known the PERSON for .

a. The PERSON has only recently displayed behavior related to substance abuse

b. The PERSON has, over a period of time, had a substance abuse problem. Specify how long:

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

7. I believe that the PERSON is substance abuse impaired (defined in the law as the use of alcoholic beverages or any psychoactive or mood-altering substance in such a manner as to induce mental, emotional, or physical problems and cause socially dysfunctional behavior):


8. I believe that the PERSON has lost the power of self-control with respect to substance use because:


9. I have seen the following behavior, which causes me to believe that the that the PERSON has inflicted, or threatened or attempted to inflict, or unless admitted for assessment is likely to inflict, physical harm on himself or herself or someone else. On at approximately I saw the PERSON:


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


11. I believe the PERSON is in need of substance abuse services because his or her judgment has been so impaired that he or she is incapable of appreciating his or her need for such services and of making a rational decision about services because (a mere refusal to receive services is not enough to constitute lack of judgment):


12. To my knowledge or belief, I do not believe these actions were a result of mental illness, retardation, developmental disability, or conditions resulting from antisocial behavior.


CHECK AND/OR ANSWER ALL APPLICABLE SECTIONS:

13. a. I have attempted to get the PERSON to agree to seek assistance for a substance abuse problem(s) as follows:

b. I did not try to get the PERSON to agree to a voluntary assessment or treatment because:

c. The PERSON refused a voluntary assessment or treatment because:

14. I have made arrangements for the PERSON to be admitted to facility located at for voluntary assessment and stabilization

15. The name of PERSON'S attorney is


16. The PERSON can cannot afford an attorney. If not, Petitioner requests the Court to appoint an attorney to represent the PERSON.

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