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Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Martin County, Florida Page 3

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Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination

15. I believe that this lack of care or neglect will lead to the PERSON hurting himself/herself because:

16. Can family or close friends provide enough care to avoid harm to the PERSON? ___Yes

___No, if not, why?

PROVIDE THE FOLLOWING IDENTIFYING INFORMATION ABOUT THE PERSON (IF KNOWN) IF IT IS

DETERMINED NECESSARY TO TAKE THE PERSON INTO CUSTODY FOR EXAMINATION:

County of Residence

Social Security No:

Date of Birth:

Sex:

Male

Female Race:

Height

Weight:

Hair Color:

Eye

Color:

Does the PERSON have access to any weapons? ___No ___Yes

If yes, describe:

Is the PERSON violent now? ______ Has the person been violent in the recent past? ____ Describe:

Does the PERSON have any criminal charges against him/her? ___No ___Yes If yes, describe:

Does the PERSON have any known communicable diseases? ___No ___Yes If yes, specify:

Does the PERSON have any insurance benefits which will pay for mental health treatment at a hospital? ___No ___Yes

If yes,

specify the closest facility at which the PERSON's benefits will pay:

Does the PERSON have a legal guardian or is there a pending petition to determine the PERSON's capacity and for the appointment of a

guardian? ___No ___Yes

If yes, provide the name, address, and phone number of the current or proposed guardian:

Name

Address

Phone Number

I understand that this sworn statement is given under oath and will be treated as though it was made before a Judge in a Court

of Law. I understand that any information in this sworn statement which is not to the best of my knowledge and done in good

faith may expose me to a criminal charge of perjury under the statutes of the State of Florida.

Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true.

Signature of Affiant/Petitioner:

SWORN TO AND SUBSCRIBED before me

this

day of

, 2009

this

day of

, 20

Who is

Carolyn Timmann, Clerk of Circuit Court

Martin County, Florida

personally known to me or presented

As identification

By:

Deputy Clerk

Notary Public - State of Florida

My Commission expires: Date

Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Martin County, Florida Page 3

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