IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA
For Clerk's Use Only
IN RE: INVOLUNTARY HOSPITALIZATION OF _________________________________, RESPONDENT
DATE: ____________________________________________ CASE NUMBER ___________ - MH - __________
If this application is GRANTED, distribute copies of the application and Form 903CC ORDER to:
Applicant, Respondent, Respondent's Attorney, Prosecuting Attorney and the Regional Mental Health Center.
APPLICATION FOR INVOLUNTARY CUSTODY FOR
MENTAL HEALTH EXAMINATION
[West Virginia Code: § 27-5-2]
DO NOT USE THIS FORM IF THE PERSON TO BE EXAMINED IS
INCARCERATED IN A JAIL, PRISON, OR OTHER CORRECTIONAL FACILITY
[USE FORM 901C]
INSTRUCTIONS TO APPLICANT:
A.
READ THOROUGHLY the IMPORTANT INFORMATION TO APPLICANTS attached.
B
All information must be printed or typed and be clearly readable.
C.
All information requested must be provided, if known. If unknown, you must state it is unknown.
D.
Any petition and application which does not provide the necessary information, or is unreadable,
may be rejected or denied. Read and answer all questions carefully.
E.
In this document, the RESPONDENT is the person whose examination is requested.
1.
FULL NAME OF PERSON TO BE EXAMINED (RESPONDENT):_____________________________________________________
Identification Information
AGE ________;WEIGHT __________; HAIR COLOR _____________; HAIR LENGTH ___________
of Respondent::
SEX ________; HEIGHT __________; EYE COLOR ______________; RACE ______________
2.
RESPONDENT'S LAST KNOWN ADDRESS: _______________________________________________________________________
______________________________________________________________________________________________________________
RESPONDENT’S TELEPHONE NUMBER: ( ) _______________________________________
3.
WHERE IS RESPONDENT NOW ? PROVIDE ADDRESS: ____________________________________________________________
________________________________________