IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA
IN RE: Involuntary Hospitalization of
Case No. ________- MH -______
NO PROBABLE CAUSE FOR INVOLUNTARY HOSPITALIZATION FOR EXAMINATION
[W.Va. Code: §27-5-2(f)]
This matter was heard on the ________ day of ___________________________, 20________. The Applicant in this cause,
___________________________________________, appeared in person [Check Appropriate Items] pro se, or was represented
by ____________________________________________, Assistant/Prosecuting Attorney of ___________________ County, West
Virginia; The Respondent appeared in person and by appointed counsel, ___________________________________; Testimony was
also presented by ____________________________________________________________________________,
Physician/Psychologist/Court approved Licensed Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric
Certification, and also by the following witnesses:
After hearing the testimony of witnesses and receiving all relevant evidence, and upon examination of the written report and
certification of the Examiner, and the arguments of counsel for the parties, the Court makes the following FINDINGS [Initial
The Respondent _________IS
a resident of ______________________ County, West Virginia.
The Respondent _________WAS _________WAS NOT
found in __________________________ County, West Virginia.
____________ The Respondent is not a resident of the State of West Virginia but is a resident of the State of __________________.
The Court further FINDS that t