Petition For Involuntary Commitment - North Dakota Page 2

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North Dakota Supreme Court

SFN 17260 (GN-1) (Rev. 08-2015)

Page 2

That the petitioner believes that the respondent is

mentally ill and as a result of such condition there is a reasonable expectation of a serious risk of harm if respondent is not treated.

chemically dependent and as a result of such condition there is a reasonable expectation of a serious risk of harm if respondent is not treated.

That because of the foregoing condition, the respondent requires treatment.

That the assertions contained in paragraph 3 are based upon the following specific facts (attach additional sheets, if necessary):

That the names, addresses, and telephone numbers of witnesses who will verify these facts are as follows:

Name:

Telephone:

Address:

City:

State:

Zip Code:

Name:

Telephone:

Address:

City:

State:

Zip Code:

That petitioner believes that

is not necessary to take the respondent into immediate custody and emergency treatment. [Immediate custody

should be requested only if the respondent is seriously mentally impaired or chemically dependent and is imminently likely to injure the respondent or

other persons if allowed to remain at liberty.]

[Complete only if immediate custody and emergency treatment requested.] Overt act(s) of the respondent which indicate the respondent is likely to injure

themself or other persons if allowed to remain at liberty are described as follows:

That to the petitioner's best knowledge

The respondent is indigent.

The respondent is not indigent.

The petitioner believes that an evaluation of the respondent's condition should be made and involuntary commitment and treatment is required.

Signature of petitioner:

Date:

Telephone:

Address:

City:

State:

Zip Code: