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Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Martin County, Florida Page 2

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Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination

6. I have known the PERSON for

(how long).

___ a. The PERSON has only recently displayed unusual kinds of behavior.

___ b. The PERSON has, over a period of time, always acted in a strange manner.

___ c. The PERSON's behavior has developed over a period of time.

COMPLETE THE FOLLOWING ONLY IF THE SECTION APPLIES TO THIS CASE:

7. I have seen the following behavior, which causes me to believe that there is a good chance that the PERSON will cause serious

bodily harm to himself/herself or others. On

(date) at approximately

am/pm (time),

I saw the PERSON:

8. Other similar behavior I have personally seen is as follows:

To my knowledge or belief, I do not believe these actions were a result of retardation developmental disability,

intoxication,

or conditions resulting from antisocial behavior or substance abuse impairment.

CHECK AND/OR ANSWER APPLICABLE SECTIONS

10. ___ a. I have attempted to get the PERSON to agree to seek assistance for a mental or emotional problem(s). I explained the

purpose of the examination (describe when, who was present, and whether you or another person explained the need for the

examination):

___ b. I did not try to get the PERSON to agree to a voluntary examination because:

___ c. The PERSON refused a voluntary examination because:

11. The following steps were taken to get the PERSON to go to a hospital for mental health care:

These steps did not work because:

12. I believe that the PERSON is unable to determine for himself/herself why the examination is necessary because:

13. I believe that the PERSON suffers from a mental illness which will keep the PERSON from being able to meet the ordinary

demands of living because:

14. I believe that without care or treatment, the PERSON is likely to suffer from neglect or refuse to care for himself/herself because:

Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Martin County, Florida Page 2