Name

County Attorney

Address

City, State, Zip

Telephone Number

Attonrey for Petitioner

MONTANA JUDICIAL DISTRICT COURT, COUNTY

* CAUSE NO.

IN THE MATTER OF *

* JUDGE

, *

* PETITION FOR COMMITMENT

Respondent. *

* TO MENTAL HEALTH FACILITY

*

* * * * * * * * * * * * * * * *

The Petition of , County Attorney, in and for the County of , State of Montana, respectfully shows:

I.

That , County Attorney of , Montana, has requested the filing of this Petition; and as such, he has an interest in the case.

II.

That the Petitioner has obtained the following information regarding the above-named Respondent:

Name:

Age:

Sex:

Marital Status:

Occupation:

III.

That Respondent is believed to be seriously mentally ill as manifested by the following facts:

.

IV.

That Respondent has been detained due to an emergency situation and it is necessary to further detain him as explained in the attached written report of the professional person causing any such detention.

V.

That the following person(s) are known or believed to be legally responsible for the care, support and maintenance of Respondent:

NAME ADDRESS

VI.

That Respondent's next of kin, to the extent known by Petitioner, are as follows:

NAME ADDRESS

VII.

That Petitioner believes the following person is willing and able to be appointed as responsible person:

NAME ADDRESS

VIII.

That the following attorney has most recently represented Respondent:

NAME ADDRESS

IX.

That Respondent is indigent and cannot afford the services of an attorney.

X.

STATEMENT OF RIGHTS

That the following is a statement of Respondent's rights as set forth in õ53-21-114 of the Montana Code Annotated:

(a) The right to notice reasonably in advance of any hearing or other court proceeding concerning him;

(b) The right in any hearing to be present, to offer evidence, and to present witnesses in any proceeding concerning him;

(c) The right in any hearing to cross-examine witnesses;

(d) The right to be represented by counsel;

(e) The right to remain silent;

(f) The right in any hearing to be proceeded against according to the rules of evidence applicable to civil matters generally;

(g) The right to view and copy all petitions on file with the court concerning him;

(h) The right to be examined by a professional person of his choice when such professional person i reasonably available;

(i) The right to be dressed in his own clothes at any hearing held pursuant to this act;

(j) The right to refuse any but lifesaving medication for up to twenty-four (24) hours prior to any hearing held pursuant to this act.

FURTHERMORE, Petitioner alleges that Respondent is a seriously mentally ill person within County, Montana.

WHEREFORE, Petitioner prays as follows:

1. That Respondent be committed to State Hospital, a mental health facility for examination and treatment for a period of no more than days.

2. That this Court immediately appoint an attorney for Respondent and issue an Order for Initial Hearing which requires the Respondent to be brought forthwith before the Court with counsel to be advised of his rights and the substantive effect of this Petition for Commitment to

State Hospital.

3. That the Respondent be detained at Hospital, Stress Unit, a mental health facility pending hearing.

DATED this day of , 19 .

Name

County Attorney