J6-710 Duc Code: PM 1'03 Case ME Page 1 or 2 Commonwealth of Kenlucky Coufl Court or Justtoe Coumy KRS 2028.100 IN THE INTEREST OF: MAM Respondent FOR (a ram . (a luvoLuNTAnv HDSPITAUZAYION neszdence (Mental illness) OR ADMISSION (Mental Retardation) [oxtofl Current Locatt I0 1/?5 Date 0' Birth Sootat Security Number 1' PETITIONEH. states tnot@ne rs: (Ptease prim) a reputable resident at 1 (ll! County, Kentucky, aw (Address) ml", and is associated the Respondent as (Phone No.) at OH (Rel fionship) a Guamted Mental Hearth Professional El a Quamted Mentat Retardatton Proiesstona} located at Kentucky. and >5 assoctated win \he Respondeni as . ernptoyod at tHospttat/Faormy, eto.) (Phone No) 2: states that the Respondent: has been hospttalized In a hospitat or a torensro taoimy tor a penod 0! so days within the preceding six (5) munlhs under the provrsions of ms 202A or 504 (11 560 day prooeedtng) rs a person mm a mentat illness 15 a person wrt'n mentat retardation, and that he she presents a danger or threat of danger 10 Seth femny or others not immedtately restrained, 3 further Siates that the name, address: and restdences 07 persons retated lo ihe Respondent are: (H unknown, so sKate) Parents drguardian- Gary Marine Ky" 0 orall'tok'l'vtl/ W608 Spouse: fl \Pt Person havtng custody: Near retetrye r\ '9 Otner:_ a La 309710 Doc. Code: Rev. 1?03 Page 2 of 4. believes that the Respondent is a person with a mental illness Cl .3 person with mental retardation because: (state reasons) {hr-Elviora?N has menial in court todm 9y ibiSOYdiLll Commie-iv Qir ?Threatening oy?a Catt) drip-tr threatened in lail his dean Win Hornth acknowimneo in: laws twain-ts be taken ?lo {asternOSci-eui? 5. states the fotiowing facts to indicate belie:c that Respondent is a danger or threat of danger to self, fartiin or others because: (state reasons) me? lith W15 Wanton issues. i-it wants tube; taken to no stall-e ir-lgesoitai hp mean MAP tweetede ?Com rim/t inmmamkd at (emu, Col (mm 6. requests that the Respondent be detained for examination, evaluation and hospitalization/admittance if he/she meets the criteria for: a a) involuntary hospitaiization and that Respondent be hospitaiized for 60 Days or 360 Days; or b) invoiuntary admission and that be admitted for an indeterminate period, to be reviewed within ?ve (5) years of entry of this admission order. 2W4 Zoe W669. Mama? '1 Date Signature of Petitioner ?d ?y I I AND swoen TO before me this day of I .dJ/j. County, Kentucky Attach copy 0t Petition to cepy of each Warrant; Summons; or Order Appointing Counsel, Setting Preliminary Hearing and Appointing Doc. Code: OE Rev. 12-03 Case N0- Pa 1 off 9 Court District Commonweaith of Kentucky Court ofJustice TRANSPORT ORDER County W0 KRS (FOR '72 HOUR HOSPITALIZATION) THE INTEREST OF: Edam Hon M, Respondent bot garroliton rig Limb? esidence DEMON Ce. Driller/time Current Location ax Telephone A verified petition for invoiuntary hospitalization having been filed, the Court having reviewed the allegations therein and having examined the petitioner under oath and it appearing to the Courtthat there is probable cause to beiieve the Respondent presents a danger or a threat of danger to himseif/herself, family or others and shouid be hospitalized; AND the Court having no objection and no objection having been made by any party to examination of the Respondent, iT iS THEREFORE ORDERED that: 1. The Respondent be delivered to if Facility, without unnecessary delay by the Sheriff or other Peace Officer of this county to be examined by a Qualified Mentai Heaith Professional who is employed by a community mental health center. i shall file a certification with this Court. 2. Following said examination, the Qualified Mental Health Pro saio 22nd a, 2.0 Date Jge Attorney's Address: Please print or type name of Judge in the space provided 30% ?3 below: Po 15M 7:5 Carvoilten W00 67 Telephone No: See 75; Lt 7 77 Executed by delivering the Respondent to: Date Signature Title Distribution: Originai - Court File Copy Reapondent?s Attorney 4 Copies Peace Officer: Respondent Peace Officer?s file and return Qualified Mentai Health Professional (Attach to this copy the completed AOC Form 710, verified Petition for involuntary Hospitalization and a blank AOC Form 712, Certification of QMHP). AGO-713 Rev. 3-06 Page 1 of 1 Commonwealth of Kentucky Court of Justice Doc. Code: OGl?i or ODH Case No. Court District County (Qt V0 ORDER KRS ZUZADZB . cue THE F: RESPONDENT: Residence: Currenttoca?on: arrol .- i. oi it? The Respondent has been examined by lT lS ORDERED that. these proceedings be dismissed and the ReSpondent released from holding; OR I: the Respondent be hospitalized for a period not to exceed seventy?two (72) hours, exciuding Weekends and holidays, at Hospital or facility in Kentucky and that the Sheriff or other peace of?cer of this county deliver the Respondent to the above-named facility within forty-eight (48) hours. lT lS FURTHER ORDERED that, if determined bthhe facility to be consistent with the treatment plan of the individual released, the Sheriff or other peace of?cer of this county shall pick up the Respondent seventy-two (72) hours from the time of admission (unless further held under KRS 202A) and return him/her toresidence or current location. Due to the Respondent being charged with the crime(s) of - now pending in County. lT lS FURTHER ORDERED that upon notification by the above-named facility, the Sheriff or other peace officer of this county shall return the Respondent to Jail to answer said charges. Date: 9?2 ,2 y- .. Judge's Signa Please pn'nt or type name of Judge in the space provided below: (TO BE COMPLETED BY HOSPITAL) Date and time of admission: - Date and time of pick up (unless otherwise notified): Copy Distribution: A Court ile;Respondent; Respondent's Attorney;Peace Officer- 3 copies (Peace Officers File, Peace Officers Retum, Hospital); and Cabinet for Human Resources.