Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Hernando County, Florida Page 2
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4Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination
(Page 2)
(Check the one box that applies)
4.
a. I or a family member are 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
______________________________________________________________________________
Explain:
_____________________________________________________________________________________
I am on good terms with the PERSON at the present time. (Check one box)
5.
Yes
No If "no", please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________
(how long).
6.
I have known the PERSON for
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
at approximately
am
pm,
___________________
____________
Date
Time
________________________________________________________________________
I saw the PERSON:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________
8.
Other similar behavior I have personally seen is as follows:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
9.
To my knowledge or belief,
I do
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:
______________________________________________________________________________________
CONTINUED
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