Form Dc 4001 PDF Details

The DC-4001 form serves as a critical tool in the Commonwealth of Virginia, designed to address situations requiring urgent mental health interventions through the process of involuntary admission for treatment. The form encompasses a wide range of scenarios, including requests for Temporary Detention Orders, outlining the need for hospitalization or treatment for individuals who are unable to volunteer due to mental illness, and highlighting circumstances that could potentially lead to harm to themselves or others. It is applicable in various legal settings, such as General District Courts and Juvenile and Domestic Relations District Courts, catering to both adults and juveniles. Through detailed sections, the form gathers comprehensive information about the respondent, including their current location, legal guardians (if juvenile), and the petitioner's relationship to the respondent, underscoring a structured approach to addressing mental health crises. Additionally, the form accommodates petitions related to inmates or acquittees on conditional release, emphasizing its broad applicability in efforts to manage mental health conditions within diverse populations. The framework laid out in the DC-4001 form not only facilitates immediate attention to pressing mental health needs but also underscores the legal and community support mechanisms in place to navigate these challenging situations, reflective of Virginia’s codes and statutes dedicated to mental health and public safety.

QuestionAnswer
Form NameForm Dc 4001
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdc4001 petition for involuntary admission for treatment virginia form

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PETITION FOR INVOLUNTARY

Temporary Detention Order No

 

 

 

 

..................................................

 

ADMISSION FOR TREATMENT

Case No

 

 

 

 

 

 

 

 

 

 

Commonwealth of Virginia

Hearing Date and Time

 

 

 

 

 

 

VA. CODE §§ 16.1-340; 16.1-340.1; 19.2-169.6; 19.2-182.9; 37.2-808 through 37.2-819

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[

]

General District Court

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

..................................................................................................................................................................

 

 

 

 

 

 

 

 

 

 

 

 

[

]

Juvenile and Domestic Relations District Court

 

 

 

 

CITY OR COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In re

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

......................................................

 

.........................................

 

 

NAME OF RESPONDENT

 

 

 

 

 

 

 

 

GENDER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.......................................................................................................................................

 

 

 

 

 

 

 

 

..............................................................................................................................

 

 

RESIDENCE ADDRESS

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS IF DIFFERENT

 

 

.......................................................................................................................................

 

 

 

 

 

 

 

..............................................................................................................................

 

 

 

 

 

 

 

 

CITY

 

 

STATE

 

ZIP CODE

CITY

 

STATE

 

ZIP CODE

...............................................................................................................................................................................................................................................................................

NAME AND ADDRESS OF CURRENT LOCATION OF RESPONDENT

...............................................................................................................................................................................................................................................................................

NAME AND ADDRESS OF PARENT/GUARDIAN/LEGAL CUSTODIAN (IF RESPONDENT IS A JUVENILE)

...............................................................................................................................................................................................................................................................................

NAME AND ADDRESS OF PARENT/GUARDIAN/LEGAL CUSTODIAN (IF RESPONDENT IS A JUVENILE)

................................................................................................................................................ .....................................................................................................................

NAME OF PETITIONERPETITIONER’S RELATIONSHIP TO RESPONDENT

 

 

 

 

 

 

 

(

.................

)

 

 

................................................................................................................................................

 

 

 

 

 

 

........................................................................................

 

 

NAME OF AGENCY OR FACILITY OF PETITIONER (IF APPLICABLE)

 

 

 

 

FACSIMILE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.................

)

 

 

................................................................................................................................................

 

 

 

 

(

 

........................................................................................

 

 

ADDRESS OF PETITIONER

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

.................

)

 

 

................................................................................................................................................

 

 

 

 

 

........................................................................................

 

 

 

 

 

 

 

 

 

CITY

 

 

STATE

 

ZIP CODE

 

 

ALTERNATE TELEPHONE NUMBER

 

I, the undersigned petitioner, being a responsible person, hereby file this petition pursuant to Virginia Code

[] §§ 37.2-805 through 37.2-819 (Adult Cases Only) and state that the respondent is unwilling to volunteer or incapable of volunteering for hospitalization or treatment, has a mental illness and is in need of hospitalization or treatment, and that there exists a substantial likelihood that, as a result of mental illness, the respondent will, in the near future:

[ ] cause serious physical harm to [ ] self [ ] others as evidenced by recent behavior causing, attempting, or threatening harm and other relevant information, if any, or

[] suffer serious harm due to respondent’s lack of capacity to protect self from harm or to provide for respondent’s own basic human needs

[ ]

I further state, based upon personal knowledge, that

...................................................................................................... meets

 

 

NAME OF PROPOSED ALTERNATIVE TRANSPORTATION PROVIDER

the criteria of an alternative transportation provider set forth in § 37.2-808 or § 37.2-810, and request the magistrate to consider authorizing transportation of the respondent by this identified person, facility or agency as an alternative to transportation by a law enforcement agency.

[] The preadmission screening report has been prepared by the community services board and the report is attached.

[] An initial mandatory outpatient treatment plan has been prepared by the community services board and is attached.

[ ] This petition is filed pursuant to Virginia Code § 37.2-817(C) prior to the expiration of the involuntary admission order entered

on

, to continue such order, of which the respondent is the subject, for a period not to exceed 180 days.

 

DATE

[] This motion for mandatory outpatient treatment is filed pursuant to Virginia Code § 37.2-805 or § 37.2-817(C) as the respondent has been the subject of a temporary detention order and voluntarily admitted himself in accordance with § 37.2- 814(B) or was involuntarily admitted pursuant to § 37.2-817(C), and on at least two previous occasions within 36 months preceding the date of the hearing, has been the subject of a temporary detention order and voluntarily admitted himself in accordance with § 37.2-814(B) or has been involuntarily admitted pursuant to § 37.2-817.

[] § 19.2-169.6 and as the person having custody over the respondent, who is an inmate, state that the inmate has a mental illness; there exists a substantial likelihood that, as a result of a mental illness, the inmate will, in the near future,

[ ] cause serious physical harm to [ ] self [ ] others as evidenced by recent behavior causing, attempting, or threatening harm and any other relevant information, or

[ ] suffers serious harm due to his lack of capacity to protect himself from harm as evidenced by recent behavior and any other relevant information;

and the inmate requires treatment in a hospital rather than a local correctional facility.

FORM DC-4001 (MASTER, PAGE ONE OF TWO) 07/13

Temporary Detention Order No. ..................................................

Case No. .................................................................................................

[] § 19.2-182.9 and state that the respondent, who is an acquittee on conditional release [ ] has violated the conditions of the respondent’s release, or

[ ] is no longer a proper subject for conditional release,

and the respondent requires inpatient hospitalization.

[ ] § 16.1-340 or § 16.1-340.1 (Juvenile Cases Only) and state that because of mental illness, the respondent, who is a juvenile:

[ ] presents a serious danger to [ ] self [ ] others to the extent that severe or irremediable injury is likely to result, as evidenced by recent acts or threats, or

[] is experiencing a serious deterioration of the ability to care for self in a developmentally age-appropriate manner, as evidenced by delusionary thinking or by a significant impairment of functioning in hydration, nutrition, self-

protection, or self-control,

and the juvenile is in need of compulsory treatment for a mental illness and is reasonably likely to benefit from the proposed treatment.

[ ] The juvenile is currently detained in a detention home or shelter care facility by order of the

............................................................................................................ Juvenile and Domestic Relations District Court. To the extent known,

NAME OF COURT

the following charges against the juvenile are the basis of the detention in the detention home or shelter care facility:

.............................................................................................................................................................................................................................................................

CHARGE

.............................................................................................................................................................................................................................................................

CHARGE

[ ] See attached sheet for additional charges.

To the extent known, the names and addresses of the juvenile’s parents are as follows:

......................................................................................................................................................................................................................................................................

NAME OF MOTHER AND ADDRESS

......................................................................................................................................................................................................................................................................

NAME OF FATHER AND ADDRESS

I request that the respondent be examined and accorded such assistance as provided by law. In support of this petition, I further state

as follows:

........................................................................................................................................................................................................................................................

..........................................................................................

______________________________________________________________

 

DATE

PETITIONER

The petitioner appeared this date before the undersigned and, upon being duly sworn, made oath that the facts stated in this petition are true based on the petitioner’s knowledge.

..........................................................................................______________________________________________________________

DATE

[ ] JUDGE [ ] MAGISTRATE

[ ] SPECIAL JUSTICE [ ] CLERK

 

 

 

 

 

FOR NOTARY PUBLIC’S USE ONLY:

 

 

 

State of

[ ] City [ ] County of

 

Acknowledged, subscribed and sworn to before me this

...................... day of

, 20

by

 

 

................................................................................

_____________________________________________________________

 

DATE

NOTARY PUBLIC

 

 

 

Notary Registration No

(My commission expires

)

 

 

 

 

FORM DC-4001 (MASTER, PAGE TWO OF TWO) 07/13

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1. To begin with, once filling out the Form Dc 4001, begin with the part that features the subsequent blanks:

Filling in section 1 in Form Dc 4001

2. The third part would be to submit the following blank fields: I the undersigned petitioner being, through Adult Cases Only and, volunteering for hospitalization, cause serious physical harm to, threatening harm and other, suffer serious harm due to, basic human needs I further, NAME OF PROPOSED ALTERNATIVE, the criteria of an alternative, The preadmission screening, This petition is filed pursuant, on to continue such order of, DATE, This motion for mandatory, and respondent has been the subject of.

on to continue such order of, I the undersigned petitioner being, and NAME OF PROPOSED ALTERNATIVE in Form Dc 4001

3. This next segment will be about Temporary Detention Order No, Case No, and state that the respondent, has violated the conditions of, and the respondent requires, or Juvenile Cases Only and, presents a serious danger to, evidenced by recent acts or, is experiencing a serious, evidenced by delusionary thinking, and the juvenile is in need of, The juvenile is currently, Juvenile and Domestic Relations, NAME OF COURT, and CHARGE - fill out each of these empty form fields.

A way to complete Form Dc 4001 step 3

4. Filling in CHARGE, See attached sheet for, To the extent known the names and, NAME OF MOTHER AND ADDRESS, NAME OF FATHER AND ADDRESS, I request that the respondent be, as follows, DATE, PETITIONER, The petitioner appeared this date, FOR NOTARY PUBLICS USE ONLY, DATE, JUDGE MAGISTRATE SPECIAL, and State of City County of is crucial in this next step - ensure to take your time and fill out each and every blank area!

Simple tips to prepare Form Dc 4001 part 4

In terms of To the extent known the names and and DATE, be certain you don't make any errors here. Both of these could be the key fields in the document.

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