Mental Health Form – Fill Out and Use This PDF

IN THE CIRCUIT COURT OF					COUNTY, MISSOURI
			PROBATE DIVISION
IN THE MATTER OF						, RESPONDENT.
DATE OF BIRTH:				GENDER: MALE			FEMALE

The applicant herein states to the Court as follows:

1. That the

respondent

, age

, birthdate

,

resides at

(STREET)

(CITY)

(COUNTY)

(STATE)

(ZIP CODE)

and is now at

.

2.That the applicant has reason to believe that the respondent is mentally disordered/abuses alcohol or drugs or both as define d by

law and presents a likelihood of serious harm to h self or others, and thus is in need of detention, evaluation and treatment/rehabilitation.

3.The facts that support the applicant’s belief that the respondent is mentally disordered/abuses alcohol or drugs or both are:

4.The facts that support the applicant’s belief that the respondent presents a likelihood of serious harm are:

5.That attached and made a part of hereof are affidavits in support of this application and the names and addresses of persons known to the applicant to have personal knowledge of the facts.

WHEREFORE, the applicant requests the Court to hold a hearing on this application and to order that the respondent, be taken in to

custody and transferred tofor

detention, evaluation and treatment/rehabilitation for a period not to exceed 96 hours pursuant to Chapter 632, RSMo/Chapter 631, RSMo.

, applicant herein, verifies and

affirms that the facts stated in the foregoing application are true to the best of h

knowledge and belief.

Attachments

DIVISION CLERK

DEPUTY DIVISION CLERK

By

APPLICANT

TELEPHONE

STREET

CITY

COUNTY

STATE

ZIP CODE

NOTARY PUBLIC EMBOSSER OR

STATE

COUNTY (OR CITY OF ST. LOUIS)

BLACK INK RUBBER STAMP SEAL

SUBSCRIBED AND SWORN BEFORE ME, THIS

DAY OF

YEAR

USE RUBBER STAMP IN CLEAR AREA BELOW.

NOTARY PUBLIC SIGNATURE

MY COMMISSION

EXPIRES

NOTARY PUBLIC NAME (TYPED OR PRINTED)

MO 650-0178N (8-07)

DMH 128