IN THE CIRCUIT COURT OF _______________________ COUNTY, WEST VIRGINIA
IN RE: Involuntary Hospitalization of
Case No. _____________- MH -_____________
___________________________________________
RESPONDENT
REPORT OF DISCHARGE OF INVOLUNTARILY HOSPITALIZED PATIENT
[W.Va. Code: §§ 27-7-1, 2, and 3]
Pursuant to the provisions of West Virginia Code: § 27-7-1, 2, and 3, comes ___________________________
[insert name of Chief Medical Officer]
___________________ the Chief Medical Officer of ________________________________________ mental
[insert name of mental health facility]
health facility and reports: [check applicable provision]
‘ Respondent was a patient at this mental health facility prior to being placed on convalescent status, has completed six (6)
months on convalescent status, and has been discharged from involuntary commitment pursuant to West Virginia Code: §
27-7-2(a).
‘ Respondent can no longer benefit from hospitalization and has been discharged from involuntary commitment pursuant to
West Virginia Code: § 27-7-1. Attached is a copy of the patient’s discharge as required by West Virginia Code: § 27-7-
1.
‘ The conditions justifying involuntary hospitalization of the Respondent no longer exist and Respondent has been discharged
from involuntary commitment pursuant to West Virginia Code: § 27-7-1. Attached is a copy of the patient’s discharge as
required by West Virginia Code: § 27-7-1.
‘ Respondent was a patient at this mental health facility prior to being released upon request as unimproved into the care of a
responsible person, has returned to this mental health facility for examination by this chief medical officer, is no longer in
need of hospitalization, has been discharged from involuntary commitment pursuant to West Virginia Code: § 27-7-3.
Pursuant to the requirements of West Virginia Code: § 27-7-1, 2, or 3, this Report has been made by this Chief
Medical Officer to:
The Circuit Court of Respondent’s county of residence, ___________________________________ County, OR
[print name of county]
Mental Hygiene Commissioner ______________________________________________ of Respondent’s
[print name of Commissioner]
county of residence,
AND, if different from Respondent’s county of residence:
The Circuit Court of _______________________________ County in which involuntary hospitalization was or
[print name of county]
OR Mental Hygiene Commissioner _______________________________________________ of the
[print name of Commissioner]
County in which involuntary hospitalization was ordered.
Given under my hand this _________ day of ______________________________________, 2 _______.
_________________________________________________________________________
CHIEF MEDICAL OFFICER OF FACILITY
C CL MH07 INV 40
