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IN THE CIRCUIT COURT OF __________________ COUNTY, WEST VIRGINIA IN RE: ___________________________________________________ [Name of Licensed Independent Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification] Address: __________________________________________ __________________________________________ Phone #: __________________________________________ Case No. _____________-P-______________ 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 ____________________, 20_____, comes the above named Licensed Independent Clinical Social Worker (WV SW License #: _______________________________) and/or Advanced Nurse Practitioner with Psychiatric Certification (WV RN 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 box(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- 8816, fax (304)558-4189, Capitol Office email at w illiju@mail.wvnet.edu, 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. [Initial all applicable certifications below and provide information requested.] SCA-MH 923 / 6-06 AUTHORIZATION PETITION Page 1 of 5 SCA-MH 923 / 6-06 AUTHORIZATION PETITION Page 2 of 5 ____ Adult Psychiatric and Mental Health Nurse Practitioner Certification #: ____________________; Expiration Date: __________________ ____ Clinical Specialist in Adult Psychiatric and Mental Health Nursing Certification #: ____________________; Expiration Date: __________________ ____ Clinical Specialist in Child and Adolescent Psychiatric and Mental Health Nursing Certification #: ____________________; Expiration Date: __________________ ____ 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)558-3666, or at 101 Dee Drive, Charleston, WV 25311. 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]. Masters Degree in Social Work was obtained from ______________________________________________________________ [insert name of college/university] on ________/_________/___________ [insert date degree awarded]. Doctorate Degree in Social Work was obtained from ______________________________________________________________ [insert name of college/university] on ________/_________/___________ [insert date degree awarded]. Petitioner also includes the following additional information which establishes particularized expertise by Petitioner in the area of MENTAL HEALTH: [add additional pages as needed] ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ SCA-MH 923 / 6-06 AUTHORIZATION PETITION Page 3 of 5 ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 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 Addition Counselor) Certification #: ____________________; Expiration Date: __________________ CAC (Certified Addictions Counselor) Certification #: ____________________; Expiration Date: __________________ CPSII (Certified Prevention Specialist Level II) Certification #: ____________________; Expiration Date: __________________ Other: [Describe] ___________________________________________________________ Certification #: ____________________; Expiration Date: __________________ Summary of Certification Requirements: _____________________________________________ _______________________________________________________________________________ Note: Certifications will be verified in good standing by contacting West Virginia Certification Board for Addiction and Prevention Professionals at (304)746-2942, fax (304)746-2943, or at 122 3rd Ave., S. Charleston, WV 25303. _______ IC&RC/AODA (The International Certification & Reciprocity Consortium/Alcohol and Other Drug Abuse) as an [Check appropriate box(es) and provide information requested.] AAODA (Advanced Alcohol and Drug Counselor) Certification #: ____________________; Expiration Date: __________________ AODA (Alcohol and Drug Counselor) SCA-MH 923 / 6-06 AUTHORIZATION PETITION Page 4 of 5 Certification #: ____________________; Expiration Date: __________________ Other: [Describe] _____________________________________________________________ Certification #: ____________________; Expiration Date: __________________ Summary of Certification Requirements: ____________________________________________ ______________________________________________________________________________ Note: Certifications will be verified in good standing by contacting IC&RC/AODA at (717)540-4457, fax (717)540-4458, or at c/o PCB, 298 S. Progress Ave., Harrisburg, PA 17109. ________ NAADAC (National Association of Alcohol and Drug Abuse Counselors) Certification Commission Certification as [Check appropriate box(es) and provide requested information.] NCAC I (National Certified Addiction Counselor, Level I) Certification #: ____________________; Expiration Date: __________________ NCAC II (National Certified Addiction Counselor , Level II) Certification #: ____________________; Expiration Date: __________________ MAC (Master Addiction Counselor) Certification #: ____________________; Expiration Date: __________________ Other: [Describe] _________________________________________________________ Certification #: ____________________; Expiration Date: __________________ 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 901 N. Washington St., Suite 600, Alexandria, VA 22314. Petitioner [check appropriate box] HAS, HAS NOT, attended an orientation course or 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 ________________________ . The institution or organization providing/sponsoring the course/training was: [Provide name and contact information for the SCA-MH 923 / 6-06 AUTHORIZATION PETITION Page 5 of 5 institution/organization.]: ______________________________________________________________________________________ __________________________________________________________________________________________________________. Petitioner includes for the Court's consideration the following additional information which establishes particularized expertise by Petitioner in the area of mental hygiene/involuntary commitment/proceedings for involuntary custody for examination: [add additional pages as needed] ________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ______________________________________________________________________________________________________. Petitioner understands that the community mental health center designated by the secretary of the department of health and human resources to serve this county must provide or arrange for examinations for involuntary hospitalization proceedings (West Virginia Code § 27-5-2(e)). VERIFICATION I, ______________________________________________________________________, the Petitioner, after making an oath or affirmation to tell the truth, certify, UNDER PENALTIES OF FALSE SWEARING as provided by law, that the information and statements contained in this Petition and the __________ [insert number] of additional pages added hereto are true and accurate to the best of my knowledge, information and belief, that any and all attached copies are true and accurate copies of the originals. I understand that if I knowingly provide FALSE information in this Petition, I could be subject to a criminal charge of false swearing. _______________________________ _________________________________________________________ Date Signature The foregoing Petition and Verification was sworn to or affirmed before me on the ______________ day of ______________________, 20______. ____________________________________________________________________ Notary Public My commission expires: ___________________________________________________________
