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IN THE CIRCUIT COURT OF THE SEVENTH JUDICIAL (Flagler County Clerk of the Circuit Court & Comptroller)

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IN THE CIRCUIT COURT OF THE SEVENTH JUDICIAL CIRCUIT
IN AND FOR FLAGLER COUNTY, FLORIDA
IN RE: CASE NO.:
PETITION AND AFFIDAVIT SEEKING EX PARTE ORDER REQUIRING INVOLUNTARY EXAMINATION
I, , being duly sworn, am filing this sworn statement
requesting a court order for the involuntary examination of:
(hereinafter referred to as PERSON).
This petition and affidavit will be included in the PERSON’S clinical record and may be reviewed by the PERSON.
I understand that by filing out this form, the PERSON may be taken by law enforcement to a mental health facility
for an examination.
I SWEAR that the answers to the following questions are given honestly, in good faith, and to the best of my
knowledge.
1. a. I live at (Full Residence Address and Phone Number) Phone No. ( )
Street: City:
State: Zip Code:
b. I work as a:
Work address: City:
State: Zip Code: Work Phone No.( )
c. The PERSON lives at, or may be found at, the following address(es):
Street Address: City:
Street Address: City:
Street Address: City:
2. I have the following relationship with the PERSON:
3. (Check the one box that applies)
a. I, or a family member have or have not previously made allegations to law enforcement
involving this PERSON on such as domestic violence,
trespassing, battery, child abuse or neglect, Baker Act, neighborhood disputes, etc. as described:
b. This PERSON has or has not previously made allegations to law enforcement about me or
my family on , such as domestic violence, trespassing,
battery, child abuse or neglect, Baker Act, etc. as described:
4. (Check the one box that applies)
a. I or a family member are not now, and have not in the past, been involved in a court case with the
person.
b. I or a family member am now, or was involved in a court case with the PERSON. This case is/was a:
Explain:
5. I am on good terms with the PERSON at the present time. Yes No. If no, explain:
6. I have known the PERSON for
a. The PERSON has only recently displayed unusual kinds of behavior.
b. The PERSON has, over a period of time, always acted in a strange manner.
c. The PERSON’S behavior has developed over a period of time.
COMPLETE THE FOLLOWING ONLY IF THE SECTION APPLIES TO THIS CASE:
7. I have seen the following behavior, which causes me to believe that there is a good chance that the PERSON
will cause bodily harm to himself/herself or others. On at
approximately , I saw the PERSON:
pm
8. Other similar behavior I have personally seen is as follows:
9. To my knowledge or belief, I do I do not believe these actions were a result of retardation,
developmental disability, intoxication, or conditions resulting from antisocial behavior or substance abuse
impairment.
CHECK AND/OR ANSWER APPLICABLE SECTIONS
10. a. I have attempted to get the PERSON to agree to seek assistance for a mental or emotional problem(s).
explained the purpose of the examination (describe when, who was present, and whether you or another
person explained the need for the examination):
b. I did not try to get the PERSON to agree to a voluntary examination because:
c. The PERSON refused a voluntary examination because:
11. The following steps were taken to get the PERSON to go to a hospital for mental health care:
These steps did not work because:
12. I believe the PERSON is unable to determine for himself/herself, why the examination is necessary because:
13. I believe that the PERSON has a mental illness which will keep the PERSON from being able to meet the ordinary
demands of living because:
14.
I believe that without care or treatment, the PERSON is likely to suffer from neglect or refuse to care for
himself/herself because:
15.
I believe that this lack of care or neglect will lead to the PERSON hurting himself or herself because:
16.
Can family or close friends now provide enough care to avoid harm to the PERSON?
Yes
No. If not, why?
Provide the following indentifying information about the person (if known) because it may be determined
necessary to take the person into custody for examination.
County of Residence: Social Security #
Date of Birth: Sex: Male Female Race:
Picture of respondent attached: No Yes
Height:
Weight:
Hair Color: Eye Color:
Does the PERSON have access to any weapons? No Yes If yes, describe:
Is the PERSON violent now? No Yes
Has the PERSON been violent in the recent past? No Yes. If yes, describe:
Guardianship:
1) Does the PERSON have a legal guardian? No Yes
2) Is there a pending petition to determine the PERSON’S capacity and for the appointment of a guardian?
No Yes
If YES to either of the above, provide the name, address and phone number of the current or proposed guardian.
Name: Phone: ( )
ST:Address: City: Zip:
Physician Name: Phone: ( )
Medications: Provide name of medications, if known.
Case Management: Provide name and phone number of case manager or case management agency, if known.
I understand that this sworn statement is given under oath and will be treated as though it was made before a
Judge in a court of law. I understand that any information in this sworn statement which is not to the best of my
knowledge and done in good faith may expose me to a penalty for perjury and other possible penalties under the
statutes of the State of Florida.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are
true.
Signature of Affiant/Petitioner:
SWORN TO AND SUBSCRIBED before me OR SWORN TO AND SUBSCRIBED before me this
this day of , day of
by
.
who is personally known to me or presented Tom Bexley
Clerk of the Circuit Court & Comptroller
as identification.
By:
Deputy Clerk
Notary Public – State of Florida
My commission expires:
A copy of this petition must be attached to an Ex Parte Order for Involuntary Examination and accompany
the person to the nearest receiving facility.
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IN THE CIRCUIT COURT OF THE SEVENTH JUDICIAL (Flagler County Clerk of the Circuit Court & Comptroller)

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Completed 22 July 2021

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