Dsamh Form 36-1 Application For Order Of Involuntary Commitment
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1
2In the District Court of __
____ County,
State of Utah
In the Matter of:
Application for Order of
Involuntary Commitment
_______
Case No:________________________
Proposed Patient (Full Name)
________
County of: __________________
(Social Security Number
______________________________, being first duly sworn upon oath, deposes and says:
Affiant
1.
That _
___ Date of Birth_________, now at: _______________
Proposed Patient
is to the best knowledge and belief of the affiant, mentally ill and should be involuntarily
committed to:__
__, pursuant to the provisions of Utah
Local Mental Health Authority
Code Annotated 62A-15-631 (2003).
Such belief is based upon the following facts, to wit:__________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2a.*
That the said _______________________, has been examined by a licensed
Proposed patient
physician or examiner which is attached hereto and by this reference made a part hereof, or
2b.* That the said _______________________, has been requested to but has
Proposed patient
refused to submit to an examination of mental condition by a licensed physician or person
qualified as a designated examiner.
(*Strike either paragraph 2a or 2b)
_____________________________
Affiant
_____________________________
Relationship to Proposed Patient
_____________________________
Address
Subscribed and sworn to before me this ______ day of ____________________, 20_____.
_____________________________
Officer Authorized to Administer Oath
DSAMH Form 36-1, Revised 2013
Utah Code Annotated 62A-15-631(1) 2002
(Page 1 of 2)
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