Petition For 180-Day Involuntary Recommitment {MC-655}

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Hospitalization of: ) ) ) ) ) ) ) ) , Respondent. Date of Birth: Case No. PETITION FOR 180-DAY INVOLUNTARY RECOMMITMENT 1. I hereby petition the Court for a 180-day involuntary recommitment of the respondent named above pursuant to AS 47.37.205. I am the director of , an approved treatment facility. 2. 3. I believe that the respondent continues to be an alcoholic or drug abuser* who is incapacitated by alcohol or drugs. continues to be at risk of serious physical harm or illness. 4. The reasons for my belief as to the respondent's condition are as follows: * AS 47.37.270(1) defines an alcohol or drug abuser as a person who demonstrates increased tolerance to alcohol or drugs, who suffers from withdrawal when alcohol or drugs are not available, whose habitual lack of self-control concerning the use of alcohol or drugs causes significant hazard to the person's health, and who continues to use alcohol or drugs despite the adverse consequences. Page 1 of 2 MC-655(12/12)(cs) PETITION FOR 180-DAY INVOLUNTARY RECOMMITMENT AS 47.37.190, and .205 American LegalNet, Inc. www.FormsWorkFlow.com 5. This application is accompanied by a Certificate of Need for Emergency/ Involuntary Commitment prepared by a licensed physician, physician's assistant, or advanced nurse practitioner, who examined the respondent within two days before submission of this petition. The respondent refused to undergo a medical examination. Date Petitioner Type or Print Name Mailing Address Phone and Fax Verification Petitioner says on oath or affirms that petitioner read this petition and believes all statements made in the petition are true. Subscribed and sworn to or affirmed before me at Alaska on (date) , (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: I certify that on (date) a copy of this petition was sent to: Petitioner of 30-day Commitment Director of Treatment Facility Respondent/Guardian Respondent's Attorney Other , Page 2 of 2 MC-655(12/12)(cs) PETITION FOR 180-DAY INVOLUNTARY RECOMMITMENT AS 47.37.190, and .205 American LegalNet, Inc. www.FormsWorkFlow.com