AMPM Policy 320-U, Exhibit 320-U-4
Petition for Court-Ordered Treatment GravelyDisabledPersonINTHESUPERIORCOURTOFTHESTATEOFARIZONAINANDFORTHECOUNTYOF
Inthe Matterof)
)MH
)
)PETITIONFORCOURT-
)ORDEREDTREATMENT
)(PursuanttoA.R.S.§36-533)re:MentalHealthServices ) DangertoSelf/Othersor
)PersistentlyorAcutelyDisabledor
)GravelyDisabled
STATEOF ARIZONA)
)ssCOUNTY OF)
)
Petitioner,beingfirstdulysworn/affirmed,allegesthat:(MedicalDirector)
1._ is,asaresultofamentaldisorder:
DangertoselfDangertoothers
Persistentlyoracutelydisabledgravelydisabledandinneedoftreatment.
2.Thecourt-orderedtreatmentalternativesthatareappropriateandavailableare:
Outpatienttreatment[A.R.S.§36-540(A)(1)].
Combinedinpatientandoutpatienttreatment[A.R.S.§36-540(A)(2)].Inpatienttreatment[A.R.S.§36-540(A)(3)].
3.Thepersonisunwillingorisunabletoaccepttreatmentvoluntarily.
4.Asummaryofthefactssupportingtheaboveallegationsisintheattachedreportsofexaminingphysicians.
5.Thepersonisresidingorpresentinthiscounty,orisadmittedtoaninstitutionpursuanttoanorderofacourtofcompetentjurisdictionsittinginthiscounty,orwhowascommittedbyanArizonatribalcourt,whichorderofcommitmentwasdulydomesticatedpursuantto
A.R.S.§12-1702etseq.
Effective Date: 7/01/20161
/ AMPM Chapter 300, Covered ServicesAMPM Policy 320-U, Exhibit 320-U-4
Petition for Court-Ordered Treatment GravelyDisabledPerson6.Thepersonisentitledtonoticeofhearingofthepetitionandmaybefoundat
(location)
7.Petitionerbelievesthepersonrequiresa:
Title14guardian;Conservator;Title36guardianAndrequeststheCourttoorderaninvestigationandreporttobemadetotheCourt
regardingthisneed.Saidneedexistsbecause:
8.Petitionerbelievestheproposedpersonneedstheimmediateservicesofatemporary
guardianconservatorandrequeststhattheCourtappointthesamebecause:
9.Petitioner believesthataddress:,istheperson’sguardian/conservator,whoshouldreceivenoticeofanyhearing.
10.AcopyofthisPetitionhasbeenmailedtothePublicFiduciaryof
Countyand(otherguardian,ifany)
PETITIONERrequeststhattheCourt:
1.Setadateforahearing;and
2.Afternoticeandhearingfindthatthepersonissufferingfromamentaldisordertheresultofwhichrendershim/herdangeroustoselforothers,persistentlyoracutelydisabled,orgravelydisabledandorderaperiodoftreatment,allassetforthinparagraphs(1)and(2)above.
3.
4.Checkifapplicable;
OrderanindependentinvestigationandreporttotheCourtregardingtheneedforaTitle14guardianorconservatororTitle36guardian.
Appointthefollowing-namedpersonastemporaryguardianand/orconservatoroftheperson,whoPetitionerbelievestobeafitandproperpersontoserveinthatcapacity;
(ProposedTemporary Guardian/Conservator) / (RelationtoPatient)(AddressofProposedTemporaryGuardian/Conservator)
ImposethedutiesofaTitle36guardianupontheperson’sA.R.S.Title14guardianwhois
Date / SignatureofPetitioner Medical DirectorSUBSCRIBEDANDSWORNtobeforemethisday of,20.
NOTARYPUBLICORDEPUTYCLERKOFTHESUPERIORCOURT
MyCommissionExpires:
Effective Date: 7/01/20161