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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|