Petition For 30 Day Commitment {MC-110}

Page 1 of 2 AS 47.30.730 MC-110 (3/19)(cs) PETITION FOR 30-DAY COMMITMENT IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Necessity ) for the Hospitalization of: ) ) Case No. , ) Respondent. ) PETITION FOR 30-DAY ) COMMITMENT As mental health professionals who have examined the respondent, the petitioners allege that: 1.The respondent is mentally ill because: 2.As a result of being mentally ill, the respondent is: Likely to cause serious harm to himself or herself because: Likely to cause serious harm to others because: Gravely disabled under AS 47.30.915(7)(A) AS 47.30.915(7)(B) and their mental condition could improve with treatment because: manifested by recent behavior causing, attempting, or threatening that harm; (B) poses a substantial risk of harm to others as manifested by recent behavior causing, attempting, or threatening harm, and is likely in the near future to cause physical injury, physical ab use, or substantial property damage to another person; or (C) manifests a current intent to carry out plans of serious harm to that person's self or another. (AS 47.30.915) Mental illness ability to exercise conscious control of their actions or ability to perceive reality or to reason or understand; mental retardation, epilepsy, drug addiction, and alcoholism do not per se constitute mental illness, although persons suffering from these conditions may also be suffering from mental illness. (AS 47.30.915) " Gravely disabled " means a condition in which a person as a result of mental illness (A) is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, or personal safe ty as to render serious accident, illness, or death highly probable if care by another is not taken [AS 47.30.915(7)(A)]; or (B) will, if not treated, suffer o r continue to suffer severe and abnormal mental, emotional, or physical distress, and this distre ss is associated with significant impairment of judgment, reason, or behavior causing a substantial deterioration of the person's previous ability to function independently. [AS 47.30.915(7)(B)] Note : In Wetherhorn v. Alaska Psychiatric Institute , 156 P.3d 371 (Alaska 2007), the (AS 47.30.915) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 AS 47.30.730 MC-110 (3/19)(cs) PETITION FOR 30-DAY COMMITMENT 3.Commitment in a treatment facility is appropriate because evaluation staff haveconsidered but not found any less restrictive alternative that would adequately protect4. is an appropriate treatment facility for the respondent's condition and has agreed to accept the respondent. The evaluation staff has considered, but has not found, any less restrictive alternatives available that would adequately protect the respondent or others. 5.The respondent has been advised of the need for, but has not accepted, voluntarytreatment.6.The following persons are prospective witnesses, some or all of whom will be asked totestify in favor of the commitment of the respondent at the hearing: 7.Additional Information: The petitioners respectfully request the court to commit the respondent to the above-named treatment facility for not more than 30 days. Date Signature of Mental Health Professional Printed Name Title Date Signature of Mental Health Professional Printed Name Title Note: This petition must be signed by two mental health professionals who have examined the respondent, one of whom is a physician. AS 47.30.730(a). " Least restrictive alternative " means mental health treatment facilities and conditions of treatment that (A) are no more harsh, hazardous, or intrusive than necessary to achieve the treatment objectives of the patient; and (B) involve no restrictions on physical movement nor supervised residence or inpatient care except as reasonably necessary for the administration of treatment or the protection of the patient or others from physical injury. (AS 47.30.915) American LegalNet, Inc. www.FormsWorkFlow.com