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Mental Hygiene Involuntary Commitment Forms
REVISED Forms are indicated below. Destroy old forms in your possession and replace with REVISED Forms below.
| Form No. | Description of Form | Signatory |
|---|---|---|
| INV 1 | Application for Involuntary Custody for Mental Health Examination | Applicant |
| INV 1M | Application for Involuntary Custody for Mental Health Examination of Minor | Chief Medical Officer (under oath) |
| INV 2 | Application for Incarcerated Individual's Mental Health Examination under WV Code 27-5-2 | Chief Administrative Officer of Correctional Facility (under oath) |
| INV 8 | Motion to Withdraw Application for Involuntary Custody for Mental Health Examination | Applicant |
| INV 10 | Certificate of Licensed Examiner | Physician/Psychologist/Ct. Approved Licensed Clinical Social Worker/Ct. Approved Advanced Nurse Practitioner/Physician Assistant |
| INV 14 | Voluntary Treatment Agreement (VTA) | Respondent + Counsel for Resp. + MHC/Judge/Magistrate |
| INV 16 | Motion for Hospitalization Due to Noncompliance with VTA | Mental Health Center or Other Movant |
| INV 21 | Motion for Cancellation or Modification of VTA | Conservator/Guardian; Notary |
| INV 26 | Chief Medical Officer's Application for Final Commitment | Chief Medical Officer |
| INV 39 | Order to Return Escaped Patient to Facility | Chief Medical Officer of Mental Health Facility |
| INV 40 | Report of Discharge of Patient | Chief Medical Officer of Mental Health Facility |
| INV 41 | Attestation of Physician:Ordering Involuntary Hospitalization (72 hour hold) | Hospital Physician |
| Court Contacts | Mental Hygiene Court Contacts | Hosptal Resources |
| EXAM 1 | Petition for Court Authorization to Perform Examinations for Probable Cause Proceedings for Involuntary Hospitalization | Licensed In dependent Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification |
| EXAM 4 | Report/Request of Court Authorized Examiner Regarding Licensing Change | Licensed Independent Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification |
