RULE 6.5A                                               
       PETITION FOR REVOCATION OF CONDITIONAL RELEASE                            
          OR LESS RESTRICTIVE TREATMENT OF A MINOR                               
                                                                                 
    The petition for revocation of conditional release or less restrictive       
treatment shall contain the following:                                           
    (a) The name and address of the petitioner and the statement that            
petitioner is the Secretary of the Department of Social and Health               
Services, State of Washington, or is the county mental health professional       
for (name) County.                                                               
    (b) The name and address of the person alleged to have failed to adhere      
to the terms and conditions of release or less restrictive treatment or          
whose functioning has substantially deteriorated. Such person shall be           
denominated the respondent.                                                      
    (c) The facts upon which the allegations of the petition are based.          
    (d) A statement that the respondent was released under terms and             
conditions of a court ordered less restrictive treatment or under terms and      
conditions set by an evaluation and treatment facility, and that a copy of       
the terms and conditions is attached to the petition, or that substantial        
deterioration of the minors functioning has occurred. The statement shall        
also contain the date the order was entered, number of days for which            
effective, and the court entering such order.                                    
    (e) The date, time and place of detention of the respondent if he/she        
is detained pursuant to an order of the secretary, or whether such an order      
has been or will be issued.                                                      
    (f) A demand that a hearing be held within 7 days of the date on which       
respondent was detained.                                                         
    (g) The petition shall describe the behavior of the minor indicating         
violation of the conditions or deterioration of routine functioning and a        
dispositional recommendation.                                                    
    (h) The petition shall be in substantially the following form, with a        
copy of the terms and conditions attached:                                       
                                                                                 
                SUPERIOR COURT OF WASHINGTON                                     
                FOR (_______________) COUNTY                                     
                                                                                 
In re the Detention of:   )               No. __________                         
                          )                                                      
                          )               PETITION FOR REVOCATION                
                          )               OF CONDITIONAL RELEASE                 
                          )                 OR LESS RESTRICTIVE                  
                          )                ALTERNATIVE TREATMENT                 
                          )                                                      
     Respondent.          )               RCW 71.34.110                          
                                                                                 
    (Petitioner), ___ Secretary of the Department of Social and Health           
Services, State of Washington, or ___ county mental health professional for      
(name) County alleges that:                                                      
    (Respondent), residing at (address) in (city or town), is a                  
___ single ___ married ___ widowed ___ divorced ___ male ___ female              
age _____.                                                                       
    Pursuant to an order of (name) court entered on (date), respondent was       
detained for involuntary treatment for a period not to exceed (number) days      
in (name of facility), or was placed on less restrictive alternative             
treatment.                                                                       
    ___ (Respondent) was conditionally released from inpatient care at           
(name of facility) prior to expiration of the court ordered period of            
detention, under terms and conditions for such release copies of which,          
including modifications, are attached and were filed in (name) court on          
(date(s)) or ___ respondent was placed on less restrictive treatment under       
terms and conditions copies of which, including modifications, are               
attached.                                                                        
    During the period of conditional release or less restrictive treatment,      
respondent was receiving outpatient care from (name of facility) located in      
(city or town), (name) County.                                                   
    Pursuant to RCW __________, petitioner ___ has ___ has not issued an         
order for the apprehension and detention of respondent and respondent ___        
is not detained ___ is detained in (name of facility) located in (city or        
town), (name) County.                                                            
    (Respondent) has failed to adhere to the terms and conditions of             
respondent's release from involuntary detention or less restrictive              
alternative treatment, the minors routine functioning has substantially          
deteriorated and ___ the conditions of release or less restrictive               
treatment should be modified or ___ the person should be placed in an            
involuntary treatment facility.                                                  
    The facts upon which the allegations of this petition are based              
are as follows: ______________________________________________________           
______________________________________________________________________           
    The petitioner requests that a hearing be held to determine whether          
respondent has failed to adhere to the terms and conditions of release or        
less restrictive treatment, or whether the minors routine functioning has        
substantially deteriorated, and whether the respondent shall be placed on        
involuntary treatment on an inpatient basis or whether the terms and             
conditions of release or less restrictive treatment shall be modified.           
    Dated this _______ day of ____________________, 19____.                      
                             _________________________________________           
                                          Petitioner                             
    Sworn and Subscribed on _________________________________________            
                             _________________________________________           
                             Notary Public for the State of Washington           
                             Residing at _____________________________           
                             My commission expires on ________________