Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Martin County, Florida
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4IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT
IN AND FOR MARTIN COUNTY, FLORIDA
IN RE:____________________________
CASE NO:__________________________
__________________________________/
Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination
I,
, being duly sworn, am filing
Print Name of Petitioner
this sworn statement requesting a Court Order for the involuntary examination of
(hereinafter referred to as PERSON).
Print Name of Person
This petition and affidavit will be included in the PERSON's clinical record and may be viewed by the PERSON.
I understand that by filling out this form, the PERSON may be taken by law enforcement to a mental health facility for an examination.
I SWEAR that the answers to the following questions are given honestly, in good faith, and to the best of my knowledge.
1. a. I live at:(Print Your Full Residence Address and Phone Number) Phone:(
)
Street Address:
City
ST
Zip
b. I work as a: (Occupation)
Work Phone: (
)
Work Street Address:
City
ST
Zip
c. The PERSON lives at, or may be found at, the following address(es):
Street Address:
City
Street Address:
City
Street Address:
City
2. I have the following relationship with the PERSON:
3. (Check the one that applies)
___ a. I or a family member ___have or ___have not previously made allegations to law enforcement involving this PERSON
on
(date) such as domestic violence, trespassing, battery, child abuse or neglect,
Baker Act, etc. as described:
___ b. This PERSON ___has or ___has not previously made allegations to law enforcement about me or my family on
(date) such as domestic violence, trespassing, battery, child abuse or neglect, Baker
Act, etc. as described:
4. (Check the one that applies)
___ a. I or a family member is not now, and have not in the past, been involved in a court case with the PERSON.
___ b. I or a family member am now, or was, involved in a court case with the PERSON. This case is/was a:
in
Type of Case
When
5. I am on good terms with the PERSON at the present time. (check one)
___ Yes.
___ No. If "no", please explain:
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