Fillable AOC-700A Doc. Code: PIHAD Court of Justice www.courts.ky.gov

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AOC-700A Doc. Code: PIHAD Court of Justice www.courts.ky.gov

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RESPONDENT'S RESIDENCE ADDRESS: (please print)
______________________________________________________________________________________
______________________________________________________________________________________
Phone Number: _________________________________
CURRENT LOCATION: (if dierent)
______________________________________________________________________________________
______________________________________________________________________________________
Phone Number: _________________________________
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AOC-700A Doc. Code: PIHAD
Rev. 6-19
Page 1 of 3
Commonwealth of Kentucky
Court of Justice www.courts.ky.gov
KRS 222.432
Case No. ____________________
Court ________________________
County ______________________
Division ______________________
IN THE INTEREST OF: ____________________________________________________________________
Respondent's Name (please print)
 
    
  
District
1. PETITIONER, ______________________________________________________________________
PETITIONER'S ADDRESS:
(please print)
___________________________________________________________________________________
___________________________________________________________________________________
Phone Number: _________________________________
states that he/she is: q Spouse; q Relative; q Friend; or q Guardian, of the above-named Respondent.
2. PETITIONER further states that the name, address, and residence of persons related to the Respondent are:
(if unknown, so state)
Parents or guardian: ___________________________________________________________________________
Spouse: _____________________________________________________________________________________
Person having custody of Respondent: _____________________________________________________________
Near relative: _________________________________________________________________________________
Other: ______________________________________________________________________________________
3. PETITIONER believes that the Respondent is a person suering from a substance use disorder because:
(state facts to support belief)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Petitioner's Name (please print)
AOC-700A
Rev. 6-19
Page 2 of 3
4. PETITIONER also believes that the Respondent presents a danger or threat of danger to self, family or others
because: (state facts to support belief)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
5. PETITIONER requests that the Respondent be detained for examination, evaluation and hospitalization/admittance
to a treatment facility if he/she meets the criteria for:
q involuntary treatment for not more than sixty (60) consecutive days; or
q involuntary treatment for not more than three hundred and sixty (360) consecutive days.
____________________________________________
Signature of Petitioner
_____________________________, 2______
Date
____________________________________________
Name of Petitioner (please print)
The Petitioner or other authorized person (spouse, relative, friend, or guardian) must guarantee all cost for treatment.
Page 3, "Guarantee of Payment," must be completed and notarized.
____________________________________________
Notary/Clerk
SUBSCRIBED AND SWORN TO before me this ________ day of __________________________, 2________
By: ____________________________________, D.C.
My Commission Expires: _________________________
AOC-700A
Rev. 6-19
Page 3 of 3

              



         


              
     
Distribution: Respondent; Petitioner; Respondent's Legal Guardian, Spouse, Parent(s), Near Relative or Friend
(if applicable).
____________________________________________

 

____________________________________________

____________________________________________


  
____________________________________________
____________________________________________
____________________________________________
Notary/Clerk
SUBSCRIBED AND SWORN TO before me this ________ day of __________________________, 2________
By: _____________________________________, D.C.
My Commission Expires: _________________________
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AOC-700A Doc. Code: PIHAD Court of Justice www.courts.ky.gov

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Completed 14 November 2021

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