Form 26.0 - Petition For Involuntary Treatment For Alcohol And Other Drug Abuse Page 2
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3CASE NO. __________
PETITIONER also believes that the Respondent presents an imminent danger or
imminent threat of danger to self, family, or others if not treated because: (state facts to
support belief)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Check one:
☐
Certificate of Physician is attached.
OR
☐
Respondent has refused all requests made by me, the Petitioner, to undergo a
physician’s examination.
Petition is accompanied by:
1.) A security deposit in the amount of $____________.
2.) Guarantee of Payment form.
________________________________
____________________________________
Signature of Attorney
Signature of Petitioner
________________________________
____________________________________
Name of Attorney (Please Print)
Name of Petitioner (Please Print)
_____
____________,
_
Sworn before me and signed in my presence on
of
20
_______________________________________________
Notary Public
VERIFICATION OF TREATMENT BY PETITIONER
***A statement from Facility MUST accompany this petition***
___________________________, the petitioner, has arranged for the treatment of
Name of Petitioner
____________________________________ to be facilitated by:
Name of Respondent
__________________________________________________________________________
Name of Treatment Provider
__________________________________________________________________________
Full Address of Treatment Provider (Street, City, State, Zip Code)
FORM 26.0 - PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE
PAGE 2
Effective Date: July 1, 2016
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