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Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Pasco County, Florida

IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT

IN AND FOR PASCO COUNTY, FLORIDA

IN RE:

CASE NO:

PETITION AND AFFIDAVIT SEEKING EX PARTE ORDER REQUIRING INVOLUNTARY EXAMINATION

, being duly sworn, am filing 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:

, State:

Zip:

b. I work as a:

(Occupation)

Work Phone: (

)

Work Street Address:

, City:

, State:

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 box that applies)

a. I or a family member

have

have not

previously made allegations to law enforcement

involving this PERSON on

(Date mm/dd/yyyy) such as domestic violence, trespassing,

battery, child abuse or neglect, Baker Act, etc. as described:

b. This PERSON

has

has not previously made allegations to law enforcement about me or

my family on

(Date mm/dd/yyyy) such as domestic violence, trespassing, battery, child

abuse or neglect, Baker Act, etc. as described.

PETITION/AFFD SEEKING EX PARTE ORD INVOL EXAM 11/98

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Petition And Affidavit Seeking Ex Parte Order Requiring Involuntary Examination Form - Pasco County, Florida

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