RULE 6.2A PETITION FOR FOURTEEN-DAY COMMITMENT OF MINORS The petition for 14-day commitment of a minor shall contain the following: (a) The names and addresses of the petitioners. The petitioners shall be two physicians or one physician and one mental health professional. (b) The name, address, age, and sex of the respondent minor. (c) The name, address and telephone number, if known, of every person believed by the petitioner to be legally responsible for the minor. (d) A statement that the minor is or is not in detention at the time the petition is filed, and, if so, the name and location of the place of detention. (e) A statement that the minor, as a result of mental disorder, presents a likelihood of serious harm to him/herself or others, or is gravely disabled. (f) A statement that the minor has been advised of the need of voluntary treatment but has been unwilling or unable to consent to necessary treatment. (g) The facts upon which the allegations of the petition are based. (h) A statement concerning whether an alternative less restrictive than inpatient treatment is in the best interest of the minor. (i) The name and location of the facility in which respondent will be detained and a statement that such facility is certified by the Department of Social and Health Services to provide evaluation and treatment to persons under 18 years of age suffering from mental disorders. (j) A statement recommending the appropriate facility or facilities to provide the necessary treatment. (k) A demand that a hearing be held to determine whether the minor shall be committed to inpatient treatment or whether an alternative less restrictive treatment exists. (l) The petition shall be in substantially the following form: SUPERIOR COURT OF WASHINGTON FOR (_______________) COUNTY In re the Detention of: ) No. __________ ) ) PETITION FOR FOURTEEN- ) DAY COMMITMENT ) OF A MINOR ) Respondent. ) RCW 71.34.070 (Petitioners) are (physician) and (physician/mental health professional). Petitioners' addresses are ____________________________ ____________________________ (Respondent), residing at (address) in (city or town), Washington, is a ___ male ___ female years of age. The name, address and telephone number of every person believed by the petitioner to be legally responsible for the minor: ______________________________________________________________________ ______________________________________________________________________ At the time of filing this petition, respondent ___ is ___ is not in detention pursuant to RCW 71.34. If respondent is in detention, the name and location of the facility in which respondent is in detention are _________________________________________________________________. Respondent, as a result of mental disorder, ___ presents a likelihood of serious harm to him/herself, ___ presents a likelihood of serious harm to others, ___ is gravely disabled. That the minor has been advised of the need for voluntary treatment and is unwilling or unable to consent to necessary treatment. The facts upon which the allegations of this petition are based are: _________________________________________________________________ ______________________________________________________________________ The following alternative courses of treatment have been considered: ______________________________________________________________________ No alternative less restrictive than detention is in the best interest of the respondent. The facility in which respondent will be detained is (name and location), certified by the Department of Social and Health Services to provide evaluation and treatment to persons under 18 years of age suffering from mental disorders. Recommended treatment facilities: _______________________________ Name _______________________________ Address The petitioner(s) request(s) that a hearing be held in the above named court to determine whether respondent shall be involuntarily committed to inpatient care or whether there shall be an alternative less restrictive treatment pursuant to RCW 71.34. Dated this _______ day of ____________________, 19____. _________________________________________ Petitioner (MD) _________________________________________ Petitioner (MD/MHP) Sworn and Subscribed on _________________________________________ _________________________________________ Notary Public for the State of Washington Residing at _____________________________ My commission expires on ________________
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