IN THE FAMILY DIVISION OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE COUNTY

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1 Code: Name: Address: Telephone No. Appearing in Proper Person IN THE FAMILY DIVISION OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE COUNTY IN THE MATTER OF THE EXAMINATION OF: (Name of Patient) ALLEGED TO BE A MENTALLY ILL PERSON. / Case No. Dept. No. APPLICATION FOR COURT ORDERED EMERGENCY ADMISSION Pursuant to NRS A.0,, the (Petitioner s name) Petitioner in this matter, who is related to the patient as follows: (Explain your relationship to the Patient) requests that this Court enter an Order involuntarily admitting (Patient s name) who resides at (Patient s street address, including City, County, and Zip Code) in the State of Nevada, to a mental health facility for evaluation, observation and treatment. It is further requested that, pursuant to NRS A.0, this Court issue an Order directing any peace officer to take the patient into protective custody and transport the patient to a mental health facility where the patient may be detained until a hearing is held. REV /0 AA 1

2 This Application is based upon my declaration regarding this matter, which is attached pursuant to NRS A.0. This document does not contain the Social Security Number of any person. I declare, under penalty of perjury under the law of the State of Nevada, that the foregoing is true and correct. DATED this day of,. (Signature) REV /0 AA

3 DECLARATION OF PETITIONER, declares: Petitioner s Name 1. I am related to the Patient in the following way:. The Patient resides at: When answering the following question, state in VERY SPECIFIC detail the date on which the event occurred, who was present, and the full surrounding circumstances.. I have probable cause to believe that (Patient s name) is mentally ill and, because of that illness, is likely to harm himself/herself or others. The basis for my belief is:. The patient has refused to submit to an examination or treatment by a physician, psychiatrist or licensed psychologist. REV /0 AA

4 . I feel there is an immediate need for this Court to order a peace officer to take the Patient into protective custody for immediate transport to a mental health facility and detention until an examination is conducted because: This document does not contain the Social Security Number of any person. I declare, under penalty of perjury under the law of the State of Nevada, that the foregoing is true and correct. When answering the following question, state your reasons clearly and in detail. DATED this day of,. (Signature) REV /0 AA

5 Code: Name: Address: Telephone Number: Acting In Proper Person IN THE FAMILY DIVISION OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE IN THE MATTER OF THE EXAMINATION OF: (Name of Patient) ALLEGED TO BE A MENTALLY ILL PERSON / Case No.: Dept. No. ORDER FOR PROTECTIVE CUSTODY AND EXAMINATION TO: ANY PEACE OFFICER Based upon the Application of, and this Court being fully advised of the circumstances herein; and, It appearing to the Court that the allegations set forth in the Application For Court Ordered Emergency Admission of present probable cause to believe this person is mentally ill, and, he/she is likely to harm himself/herself if allowed to remain at liberty at this time, pursuant to NRS A.0, IT IS HEREBY ORDERED that, pursuant to NRS A., be transported to, and examined by, a licensed physician to determine whether he/she has a medical problem rather than a psychiatric problem which requires immediate treatment. IT IS FURTHER ORDERED that, if the licensed physician finds that no medical problem Revised 0/0 1

6 exists which requires immediate treatment, shall immediately be transported to Northern Nevada Adult Mental Health Services. Said person resides, or can be found, at. IT IS FURTHER ORDERED that the patient be evaluated by a psychiatrist, psychologist, or physician as set forth in NRS A.0() to determine whether the patient will be admitted to the mental health facility. IT IS FURTHER ORDERED that the provisions of NRS.0 apply to this patient, in that, if it is determined the patient is to be admitted to the facility under the provisions of NRS A.0, the patient must be released within hours, including weekends and holidays, from the time of his or her admission unless within that period of time a written petition for an involuntary court-ordered admission is filed with the clerk of the district court pursuant to NRS A.0, including, without limitation, the documents required pursuant to NRS A.0, or the status of the person is changed to a voluntary admission. If the hour period for release expires on a day which the office of the clerk of the district court is not open, the written petition must be filed on or before the close of the business day next following the expiration of the hour period. Under these circumstances, the patient s stay at the facility may be extended only for the additional time in which to file the petition. Dated: COURT MASTER DISTRICT JUDGE Revised 0/0