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IL462 2210 IL462 2210 (Lake Land College)

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IL462-2210 (R-11-12) Petition For Involuntary Outpatient Admission
Printed by Authority of the State of Illinois -0- Copies
CIRCUIT COURT FOR THE
COUNTY
IN THE MATTER OF
Docket No.
Admission on an outpatient basis by court order; (405 ILCS 5/3-750).
Respondent submitted written notice of desire to be discharged; (405 ILCS 5/3-403).
Respondent failed to reaffirm a desire to continue treatment; (405 ILCS 5/3-404).
Respondent continues to be subject to involuntary admission; (405 ILCS 5/3-813).
I assert that
PETITION FOR INVOLUNTARY OUTPATIENT ADMISSION
STATE OF ILLINOIS
JUDICIAL CIRCUIT
(Name of Respondent)
)
)
)
)
)
)
Who is asserted to be a person subject to involuntary outpatient admission and for whom this petition is being initiated by
reason of: (select one)
*1-119 (1): A person with mental illness who because of his or her illness is reasonably expected, unless treated on an
inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable
expectation of being physically harmed; or
(2): A person with mental illness who because of his or her illness is unable to provide for his or her basic
physical needs so as to guard himself or herself from serious harm without the assistance of family
or others, unless treated on an inpatient basis; or
(3): A person with mental illness who:
(i) refuses treatment or is not adhering adequately to prescribed treatment;
(ii) because of the nature of his or her illness, is unable to understand his or her need for treatment; and
(iii) if not treated on an inpatient basis, is reasonably expected, based on his or her behavioral history,
to suffer mental or emotion deterioration and is reasonably expected, after such deterioration, to
meet the criteria of either paragraph (1) or paragraph (2) of this section.
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IL462-2210 (R-11-12) Petition For Involuntary Outpatient Admission
Printed by Authority of the State of Illinois -0- Copies
I base the foregoing assertion on the following (provide a detailed statement including a description of the signs and
symptoms of a mental illness and of any acts, threats, or other behavior or pattern of behavior supporting the assertion and the
time and place of their occurrence). ADDITIONAL PAGE(s) ATTACHED AS NECESSARY::
Below is a list of all witnesses by whom the facts asserted may be proven (include addresses and phone numbers):
I do
I do not
I am
I am not
I do
I do not
Although I have indicated that I have a legal or financial interest in this matter or that I am involved in litigation with the
respondent, I believe it would not be practicable or possible for someone else to be the petitioner for the following reasons:
Listed below are the names and addresses of the spouse, parent, guardian, or substitute decision maker, if any, and close
relative or, if none, a friend of the respondent whom I have reason to believe may know or have any of the other names and
addresses. If names and addresses are not listed below, I made a diligent inquiry to identify and locate these individuals and the
following describes the specific steps taken by me in making this inquiry (additional page(s) may be attached as
necessary):
No certificate is attached.
One certificate is attached.
Two certificates are attached.
have a legal interest in this matter.
have a financial interest in this matter.
involved in litigation with the respondent.
* Each certificate must be completed within 72 hours of examination of respondent.
** At least one certificate must be completed by a psychiatrist.
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IL462-2210 (R-11-12) Petition For Involuntary Outpatient Admission
Printed by Authority of the State of Illinois -0- Copies
Date:
Signed:
Printed Name:
Address:
Telephone Number:
Relationship to Respondent:
If respondent requests and is approved for voluntary or informal admission prior to adjudication, I wish to be notified using
the contact information supplied below. (Hospital staff use form IL462-2203 for notification purposes).
If respondent is discharged, I wish to be notified using the contact information supplied below. (Hospital staff use form
IL462-2208M for notification purposes).
I do not wish to be notified in either of the two situations described above.
Date/Time of Admission:
Signed:
Printed Name:
Title:
The petitioner can request to be notified if the facility director approves the respondent's request for voluntary or informal
admission prior to adjudication. The petitioner may also request to be notified of the respondent's discharge under section 3-902
(d) of the Mental Health and Developmental Disabilities Code. Failure to indicate a choice will be treated as a decision NOT to be
notified.
The petitioner has made a good faith attempt to determine whether the recipient has executed a power of attorney for health
care under the Power of Attorney for Health Care Law or a declaration for mental health treatment under the Mental Health
Treatment Preference Declaration Act and to obtain copies of these instruments if they exist.
I have read and understood this petition and affirm that the statements made by me are true to the best of my knowledge.
I further understand that knowingly making a false statement on this Petition is a Class A Misdemeanor.
Within 12 hours of admission to the facility under this status, I gave the respondent a copy of this Petition (MHDD-5). I
have explained the Rights of Admittee to the respondent and have provided him or her with a copy of it. I have also
provided him or her with a copy of Rights of Individuals Receiving Mental Health and Developmental Services (MHDD-1)
and explained those rights to him or her (405 ILCS 5/3-609).
To Mental Health Facility/Psychiatric Unit
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IL462-2210 (R-11-12) Petition For Involuntary Outpatient Admission
Printed by Authority of the State of Illinois -0- Copies
RIGHTS OF ADMITTEE
1. If you have been brought to this facility on the basis of this petition alone, you will not be immediately admitted, but
will be detained for examination. You must be examined by a qualified professional within 24 hours or be released.
2. When you are first examined by a physician, clinical psychologist, qualified examiner, or psychiatrist, you do not
have to talk to the examiner. Anything you say may be related by the examiner in court on the issue of whether you
are subject to involuntary or judicial admission.
3. At the time that you have been certified, and a copy of the petition and certificate will be filed with the court and you may
be admitted to the facility. A copy of the petition shall also be given to you.
4A. If you are alleged to be subject to involuntary admission (mentally ill) you must also be examined within 24 hours
excluding Saturdays, Sundays, and holidays by a psychiatrist (different from the first examiner) or be released. If
you are alleged to be subject to involuntary admission the court will set the matter for a hearing.
4B. If you are alleged to be subject to judicial admission (developmentally disabled) the court will set a hearing upon receipt of
the diagnostic evaluation which is required to be completed within 7 days.
5A. If you are alleged to be subject to involuntary admission (mentally ill) and if the facility director approves, you may
be admitted to the facility as a voluntary admittee upon your request any time prior to the court hearing. The court may
require proof that voluntary admission is in your best interest and in the public interest.
5B. If you are alleged to be subject to judicial admission (developmentally disabled) and if the facility director approves, you
may decide that you prefer to admit yourself to the facility rather than have the court decide whether you ought to
be admitted. You may make the request for administrative admission at any time prior to the hearing. The court may
require proof that administrative admission is in your best interest and the public interest.
6. You have the right to request a jury.
7. You have the right to request an examination by an independent physician, psychiatrist, clinical psychologist, or
qualified examiner of your choice. If you are unable to obtain an examination, the court may appoint an examiner
for you upon your request.
8. You have the right to be represented by an attorney. If you do not have funds or are unable to obtain an attorney,
the court will appoint an attorney for you.
9. You have the right to be present at your court hearing.
10. As a general rule, you do not lose any of your legal rights, benefits, or privileges simply because you have been
admitted to a mental health facility (see your copy of the "Rights of Individuals"). However, you should know that
persons admitted to mental health facilities will be disqualified from obtaining Firearm Owner's Identification Cards,
or may lose such cards obtained prior to admission.
11. Information about the health care services you receive at a mental health or developmental disabilities facility is
protected by privacy regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
(P.O. 104-191) at 45 CFR 160 and 164. Your personally identifiable health information will only be used and/or
released in accordance with HIPAA and the Illinois Mental Health and Developmental Disabilities Confidentiality Act
[740 ILCS 110].
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IL462-2210 (R-11-12) Petition For Involuntary Outpatient Admission
Printed by Authority of the State of Illinois -0- Copies
English
Spanish
Other
Specify language:
on
Time:
Signature:
Title:
Printed Name:
I certify that I provided respondent with a copy of this form.
A Guardianship and Advocacy Commission is a state agency consisting of three divisions: Legal Advocacy Services, Human
Rights Authority and the Office of the State Guardian. The Commission is located at the following addresses:
East Central Regional Office Peoria Regional Office Rockford Regional Office
2125 S. First Street 401 N. Main Street, Suite 620 4302 N. Main Street, Suite 108
Champaign, IL 61820 Peoria, IL 61602 Rockford, IL 61103
Phone: (217) 278-5577 Phone: (309) 671-3030 Phone: (815) 987-7657
Fax: (217) 278-5588 Fax: (309) 671-3060 Fax: (815) 987-7227
Egyptian Regional Office West Suburban Regional Office Metro East Regional Office
47 Cottage Drive Madden Mental Health Center Holly Bldg., 4500 College
Anna, Illinois 62906-1669 1200 S. First Street, P.O. Box 7009 Suite 100
Phone: (618) 833-4897 Hines, IL 60141 Alton, IL 62002
Fax: (618) 833-5219 Phone: (708) 338-7500 Phone: (618) 474-5503
Fax: (708) 338-7505 Fax: (618) 474-5517
North Suburban Regional Office Chicago Regional Office Springfield Regional Office
9511 Harrison Avenue 160 N. La Salle Street 521 Stratton Building
Des Plaines, Illinois 60016 Suite S500 401 S. Spring Street
Phone: (847) 294-4264 Chicago, IL 60601 Springfield, IL 62706
Fax: (847) 294-4263 Phone: (312) 793-5900 Phone: (217) 785-1540
Fax: (312) 793-4311 Fax: (217) 524-0088
Equip for Equality, Inc. is an independent, not-for-profit organization that administers the federal protection and advocacy system to
people with disabilities in Illinois. Equip for Equality, Inc., provides self-advocacy assistance, legal services, education, public policy
advocacy, and abuse investigations. The offices are located at:
Main/Chicago Office Central Illinois Northwestern Illinois Southern Illinois
20 N. Michigan, Ste 300 1 West Old Capitol Plaza, Suite 816 1515 Fifth Avenue, Suite 420 300 E. Main Street, Suite 18
Chicago, Illinois 60602 Springfield, IL 62701O Box 276 Moline, IL 61265 Carbondale, IL 62901
(800) 537-2632 or (217) 544-0464 (309) 786-6868 (618) 457-7930
(312) 341-0022 (800) 758-0464 (800) 758-6869 (800) 758-0559
TTY: (800) 610-2779 TTY: (800) 610-2779 TTY: (800) 610-2779 TTY: (800) 610-2779
Fax: (312) 341-0295 Fax: (217) 523-0720 Fax: (309) 797-8710 Fax: (618) 457-7985
Website: www.equipforequality.org
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IL462 2210 IL462 2210 (Lake Land College)

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Completed 11 August 2021

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