Dsamh Form 0003 - State Of Utah - Notice Of Proceeding Of Child For Commitment Of Physical Custody To
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1STATE OF UTAH
NOTICE OF PROCEEDING OF CHILD FOR
COMMITMENT OF PHYSICAL CUSTODY TO
_____________________________
Local Mental Health Authority
TO:
_____________________________
___________________________________
Child (person under 18 years of age)
Parent/Legal Guardian
_____________________________
___________________________________
Person who submitted petition
LMHA Representative
_____________________________
___________________________________
In accordance with Utah Code Annotated 62A-15-703(5)(b), please be informed that a commitment
proceeding will be conducted to determine if ___________________________, meets the criteria established
Child
in UCA 62A-15-703(4) for commitment of physical custody to ______________________________________.
Local Mental Health Authority
This proceeding will be held on: _____________________, 20_____, at _________ am/pm and will be
Date
Time
heard at: ________________________________________________________________________________.
Address and room number
You may attend this proceeding and address the petition for commitment. If you have any questions
regarding this proceeding, please contact:
_________________________________________
Name/Title
Phone
_________________________________________
Name/Title
Phone
Person(s) to be notified:
Date Notified
Time Notified
How Notified (Circle One)
□
Child (person under 18 years of age)
___/___/___
________ AM/PM
(Verbal or Written)
□
Parent/Legal Guardian
___/___/___
________ AM/PM
(Verbal or Written)
□
Person who submitted petition
___/___/___
________ AM/PM
(Verbal or Written)
□
LMHA Representative
___/___/___
________ AM/PM
(Verbal or Written)
□
Other
___/___/___
________ AM/PM
(Verbal or Written)
Instructions: “The child, the child’s parents or legal guardian, the person who submitted the petition for commitment and a representative of the
appropriate local mental health authority shall all receive informal notice of the date and time of the proceeding. Those parties shall also be afforded
and opportunity to appear and address the petition for commitment.” UCA 62A-115-703((5)(b)
DSAMH Form 0003 (Revised 2012)
Utah Code Annotated 62A-15-703
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