Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Hernando County, Florida
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4IN THE CIRCUIT COURT OF THE FIFTH JUDICIAL CIRCUIT
IN AND FOR HERNANDO COUNTY, FLORIDA
IN RE: ____________________________________ CASE NO.: ____________________________________
Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination
____________________________________
I,
, being duly sworn, am filing this sworn statement requesting a court order for the
Print Name of Petitioner
______________________________________________
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:
_______________________________________________________________________________________
(Check the one box that applies)
3.
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,
____________
______________________________________________________
neighborhood disputes, 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:
_______________________________________________________________________________________
CONTINUED
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