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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.
| Description of Form | Signatory |
|---|---|
| Application for Involuntary Custody for Mental Health Examination with Important Information to Applicants [Revised Nov. 2009] | Applicant (under oath) |
| Application for Involuntary Custody for Mental Health Examination of Minor | Chief Medical Officer (under oath) |
| Application for Incarcerated Individual's MentalHealth Examination under WV Code 27-5-2 [Revised Nov. 2009] | Chief Administrative Officer of Correctional Facility (under oath) |
| Motion to Withdraw Application for Involuntary Custody for Mental Health Examination | Applicant (under oath) |
| Certificate of Licensed Examiner [Revised Sept. 2012] | Physician/Psychologist/Ct. Approved Licensed Clinical Social Worker/Ct. Approved Advanced Nurse Practitioner/Physician Assistant |
| Voluntary Treatment Agreement (VTA) | Respondent + Counsel for Resp. + MHC/Judge/Magistrate |
| Motion for Hospitalization Due to Noncompliance with VTA | Mental Health Center or Other Movant |
| Motion for Cancellation or Modification of VTA | Conservator/Guardian; Notary |
| Chief Medical Officer's Application for Final Commitment [REVISED] | Chief Medical Officer |
| Order to Return Escaped Patient to Facility | Chief Medical Officer of Mental Health Facility |
| Report of Discharge of Patient | Chief Medical Officer of Mental Health Facility |
| Petition for Court Authorization to Perform Examinations for Probable Cause Proceedings for Involuntary Hospitalization [Revised] | Licensed In dependent Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification |
| Report/Request of Court Authorized Examiner Regarding Licensing Change [Revised] | Licensed In dependent Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification |