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 ________________
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