IN THE CIRCUIT COURT OF __________________ COUNTY, WEST VIRGINIA
IN RE: Involuntary Hospitalization of
Case No. ________- MH -________
GRANTING APPLICATION FOR INSTITUTION OF FINAL COMMITMENT PROCEEDINGS
[W.Va. Code: §§27-5-3, 27-4-3(c), and 27-5-4]
Pursuant to West Virginia Code: §§ 27-5-4 and either 27-5-3 or 27-4-3(c), _______________________________________,
Chief Medical Officer of ________________________________________________ mental health facility, has made application to
this Court for the institution of final commitment proceedings for the Respondent.
The Court has reviewed the application and FINDS it meets the requirements of West Virginia Code: §§ 27-5-4 and either
27-5-3 or 27-4-3(c).
Accordingly, it is ORDERED:
That a hearing on this application be held on the __________ day of ______________________________, 20______, at the
hour of _________M. at [location] ________________________________________________________________________
________________________________________________, or as soon thereafter as counsel may be heard.
That the Clerk of the Circuit Court give notice of this hearing as required by West Virginia Code: § 27-5-4(e) and to the
Sheriff of _____________________________________________ County, West Virginia.
That _________________________________________ is hereby appointed to examine the Respondent prior to said hearing
and to report the results of the examination thereof to this Court at said Hearing. [SEE: West Virginia Code: § 27-5-4(f).]
In the event that Respondent has not retained an attorney or cannot afford an attorney, it is further ORDERED that
____________________________________________, is hereby appointed as the Respondent's attorney and further that the
Clerk of the Circuit Court shall inform the Respondent of said attorney's name, address and telephone number.
It is further ORDERED that the Sheriff of ______________________________________ County s