IN THE CIRCUIT COURT OF _________________ COUNTY, WEST VIRGINIA
IN RE: Involuntary Hospitalization of
Case No. ________- MH -________
AUTHORIZATION AND ORDER:
CUSTODY AND TRANSPORT [RETURN] TO MENTAL HEALTH FACILITY
[W.Va. Code: §27-7-4]
On the _______ day of ____________________, 20_____, came _______________________________________, Chief
Medical Officer for ______________________________________________________________ mental health facility and presented
to the Court a sworn notice that _____________________________________________________ was admitted to such mental health
facility by involuntary commitment Order of this Court and was released under the provisions of West Virginia Code: § 27-7-2 or 3.
Said sworn notice further states that there is reason to believe that it is in the best interests of the Respondent to be hospitalized and
stated certain facts concerning the condition of the patient, the contents of which notice are hereby incorporated herein by reference.
This Court FINDS the Notice sets forth facts which are sufficient to meet the requirements of West Virginia Code: § 27-7-4,
and is further satisfied that the condition of the Respondent warrants his/her return to the mental health facility.
Accordingly, it is ORDERED that any health officer or police officer and/or the Sheriff of this County is hereby authorized
to take the Respondent into custody and to transport him/her to ________________________________________________________
__________________________________ mental health facility.
JUDGE OF THE CIRCUIT COURT
SCA-MH 920 / 4-02