Petition For Authorization To Perform Examinations For Involuntary Hospitalization {EXAM 1}

IN THE CIRCUIT COURT OF IN RE: [Name of Licensed Independent Clinical Social Worker, Advanced Nurse Practitioner with Psychiatric Certification, or Physician Assistant] Address: COUNTY, WEST VIRGINIA Case No.: Phone #: -P- City: State: Zip: PETITION FOR COURT AUTHORIZATION TO PERFORM EXAMINATIONS FOR PROBABLE CAUSE PROCEEDINGS FOR INVOLUNTARY HOSPITALIZATION [W. Va. Code: §27-5-2(e)] On this day of [month], [year], comes the above named ) Licensed Independent Clinical Social Worker (WV SW License #: and/or Advanced Nurse Practitioner with Psychiatric Certification (WV RN License #: ) and/or Physician Assistant (WV License #: ) (hereinafter referred to as "Petitioner") and petitions the Court pursuant to West Virginia Code § 27-5-2(e) for authorization to perform examinations for probable cause proceedings for involuntary hospitalization. Attached for the Court's review and consideration is/are Petitioner's current and valid license(s): [Petitioner MUST attach a copy of the applicable license(s) identified below. Check appropriate boxe(es).] A copy of Petitioner's license as an Independent Clinical Social Worker issued by the West Virginia Board of Social Work Examiners pursuant to the provisions of West Virginia Code §§ 30-30-1, et. seq. Note: Licensing will be verified in good standing by contacting the West Virginia Board of Social Work Examiners at (304) 558-4189, or at P.O. Box 5459, Charleston, WV 25361. A copy of Petitioner's license as a Registered Professional Nurse with Psychiatric Certification and Letter of Recognition as an Advanced Nurse Practitioner issued by the West Virginia Board of Examiners for Registered Professional Nurses pursuant to the provisions of West Virginia Code §§ 30-7-1, et seq., and §§ 19-7-1, et. seq., Title 19, Series 7, Legislative Rules of the West Virginia Board of Examiners for Registered Professional Nurses. EXAM 1 Rev. 11/2013 Authorization Petition American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 6 [Initial all applicable certifications below and provide information requested.] Adult Psychiatric and Mental Health Nurse Practitioner ; Expiration Date: Certification #: Clinical Specialist in Adult Psychiatric and Mental Health Nursing ; Expiration Date: Certification #: Clinical Specialist in Child and Adolescent Psychiatric and Mental Health Nursing ; Expiration Date: Certification #: Other Psychiatric Certification: [insert name of certification] Certification #: ; Expiration Date: Note: Nursing License and Certifications will be verified in good standing by contacting West Virginia Board of Examiners for Registered Professional Nurses at (304) 558-3596, fax (304) 558-8816, or at 101 Dee Drive, Charleston, WV 25311. A copy of Petitioner's license as a Physician Assistant issued by the West Virginia Board of Medicine pursuant to the provisions of West Virginia Code §§ 30-3-1, et. seq. and/or issued by the West Virginia Board of Osteopathy pursuant to the provisions of West Virginia Code §§ 30-14A-1, et. seq. Petitioner also includes for the Court's consideration the following educational information: [Check all applicable boxes and complete the requested information. At least one MUST be completed.] Masters Degree in Nursing was obtained from [insert name of college/university] on [insert date degree awarded: mm/dd/yyyy]. Masters Degree in Social Work was obtained from [insert name of college/university] on [insert date degree awarded: mm/dd/yyyy]. Doctorate Degree in Social Work was obtained from [insert name of college/university] on [insert date degree awarded: mm/dd/yyyy]. Baccalaureate Degree in Primary Health Care or Surgery from [insert name of college/university] on [insert date degree awarded: mm/dd/yyyy]. Masters Degree in Primary Health Care or Surgery from [insert name of college/university] on [insert date degree awarded: mm/dd/yyyy]. American LegalNet, Inc. www.FormsWorkFlow.com EXAM 1 Rev. 11/2013 Authorization Petition Page 2 of 6 Petitioner also includes the following additional information which establishes particularized expertise by Petitioner in the area of MENTAL HEALTH: [add additional pages as needed] Petitioner also includes for the Court's consideration the following evidence of particularized expertise in the area of ADDICTION. Petitioner holds the following addiction certifications from the: [Initial all applicable addiction certifications and provide information requested.] West Virginia Board for Addiction and Prevention Professionals as a: [check appropriate box(es) and provide information requested.] CCAC (Certified Clinical Addiction Counselor) Certification #: CAC (Certified Addictions Counselor) Certification #: ; Expiration Date: CPSII (Certified Prevention Specialist Level II) ; Expiration Date: Certification #: Other: [Describe] Certification #: Summary of Certification Requirements: ; Expiration Date: ; Expiration Date: Note: Certifications will be verified in good standing by contacting West Virginia Certification Board for Addiction and Prevention Professionals at (304) 768-2942, fax (304) 768-1562, or at 436 12th Street, Suite C, Dunbar, WV 25064. IC&RC/AODA (The International Certification & Reciprocity Consortium/Alcohol and Other Drug Abuse) as an [check appropriate box(es) and provided information requested.] AAODA (Advanced Alcohol and Drug Counselor) ; Expiration Date: Certification #: AODA (Alcohol and Drug Counselor) Certification #: Other: [Describe] Certification #: EXAM 1 Rev. 11/2013 Authorization Petition ; Expiration Date: ; Expiration Date: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 6 Summary of Certification Requirements: Note: Certifications will be verified in good standing by contacting NAADAC at (800) 548-0497, fax (800) 377-1136, or at 1001 N. Fairfax Street, Suite 201, Alexandria, VA 22314. HAS HAS NOT, attended an orientation training on mental hygiene/involuntary commitment/proceedings for involuntary custody for examination provided by The West Virginia Supreme Court of Appeals, or a similar course/training on West Virginia's law provided by another institution or organization. If Petitioner has attended such a course/training, attached is a copy of the Certificate of Attendance issued by the institution or organization offering said course/training. The date of attendance was , and the number of course/continuing education hours were . Petitioner [check appropriate box] The institution or organization providing/sponsoring the course/training was: [