RULE 6.4A                                               
      PETITION FOR ONE HUNDRED EIGHTY-DAY INVOLUNTARY                            
                    TREATMENT OF A MINOR                                         
                                                                                 
    The petition for 180-day involuntary treatment of a minor shall contain      
the following:                                                                   
    (a) The name and address of the person filing the petition and the           
statement that the petitioner is the professional person in charge of the        
facility in which the person who is alleged, as a result of mental               
disorder, to present a likelihood of serious harm to others or is gravely        
disabled, is detained, or in the event that the defendant has received           
involuntary treatment but has not been committed to a treatment facility or      
has been conditionally released from such a facility, a statement that the       
petitioner is the county mental health professional of (name) County.            
    (b) The name and address and age of the minor alleged, as a result of a      
mental disorder, to present a likelihood of serious harm to him/herself,         
others, or property or continues to be disabled. Such minor shall be             
denominated the respondent.                                                      
    (c) The name of the court ordering involuntary treatment for which the       
respondent is presently detained, and the date on which such order was           
entered.                                                                         
    (d) A summary of the facts supporting the allegations of the petition.       
    (e) A demand that a hearing be held within 7 days of the filing of the       
petition for 180-day treatment on the issue of whether the minor alleged,        
as a result of mental disorder, to present a likelihood of serious harm or       
is gravely disabled, shall be detained for involuntary treatment for a           
period not to exceed 180 days.                                                   
    (f) A statement that the minor is in need of further treatment that can      
only be provided in a 180-day commitment and this treatment is in the            
minors best interests.                                                           
    (g) A statement that less restrictive alternative treatment is/is not        
available and/or appropriate.                                                    
    (h) The petition shall be supported by accompanying affidavits signed        
by two examining physicians, one of whom shall be a child psychiatrist, or       
by one examining physician and one children's mental health specialist.          
    (i) The petition shall be in substantially the following form:               
                                                                                 
                SUPERIOR COURT OF WASHINGTON                                     
                FOR (_______________) COUNTY                                     
                                                                                 
In re the Detention of:   )               No. __________                         
                          )                                                      
                          )               PETITION FOR ONE HUNDRED               
                          )               EIGHTY-DAY INVOLUNTARY                 
                          )               TREATMENT OF A MINOR                   
                          )                                                      
     Respondent.          )               RCW 71.34.090                          
                                                                                 
    (Petitioner), professional person in charge of (name of facility) in         
which (respondent) is detained for (number) days pursuant to an order of         
(name of court) entered on (date) alleges that:                                  
    (Respondent), residing at (address) in (city or town), is a                  
___ single ___ married ___ widowed ___ divorced ___ male ___ female              
age _____.                                                                       
    (Respondent) ___ presents a likelihood of serious harm to him/herself        
or ___ presents a likelihood of serious harm to others or ___ presents a         
likelihood of serious harm to property or ___ is gravely disabled.               
    (Respondent) ___ has threatened, attempted or actually inflicted harm        
on another person, or substantial damage upon the property of another            
during respondent's current period of court ordered treatment and a s            
result of mental disorder presents a likelihood of serious harm to other,        
or ___ was taken into custody as a result of conduct in which respondent         
attempted or inflicted serious physical harm upon the person of another and      
continues to present as a result of mental disorder a likelihood of serious      
harm to others, or ___ is in custody pursuant to RCW 71.05.280(3) (acts          
constituting a felony) and as a result of mental disorder presents a             
substantial likelihood of repeating similar acts, or ___ continues to be         
gravely disabled.                                                                
    Summary of facts supporting the petition: _______________________            
______________________________________________________________________           
______________________________________________________________________           
______________________________________________________________________           
    A form of treatment less restrictive than involuntary detention              
___ is or ___ is not in the best interest of the respondent or others.           
    The petitioner requests that a hearing be held to determine whether          
(respondent) shall be detained for involuntary treatment for a period not        
to exceed 180 days.                                                              
    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 ________________