Mental Health Procedures Act Of 1976 Page 6
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6PART IV
(CONTINUED)
The court finds that the patient
is
is not appropriate for transfer to an approved
facility. Accordingly, the court orders that:
(Check A or B below)
A.
_____________________________________ receive treatment as a severely mentally
(NAME OF PATIENT)
disabled person pursuant to the provisions of the Mental Health Procedures Act of 1976 for a period of
time not to exceed those required by the original court order at
________________________________________________________________________
(NAME OF FACILITY)
B.
The person is not subject to transfer.
(Check appropriate block)
The patient was represented by
(NAME OF ATTORNEY)
(ADDRESS OF ATTORNEY)
The patient was declined representation:
For the court
(MENTAL HEALTH REVIEW OFFICER/JUDGE)
(PRINT NAME OF MENTAL HEALTH REVIEW OFFICER/JUDGE)
(DATE)
PAGE 6 OF 6
MH 788 3/07
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