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

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Page 1 of 5
IN THE CIRCUIT COURT OF THE SEVENTH JUDICIAL
CIRCUIT IN AND FOR FLAGLER COUNTY, FLORIDA
IN RE: CASE NO:
Respondent
PETITION FOR INVOLUNTARY TREATMENT
By authority of Chapter 397, Florida Statutes
I/We, being duly sworn, am filing this sworn statement
requesting a court order for the involuntary assessment of
(hereinafter referred to as PERSON).
1.
The PERSON is 18 years of age or older? Yes
or No AGE OF PERSON:
2. The PERSON lives at, or may be found at, the following address(es):
Street Address:
City: ST: Zip:
Street Address:
City: ST: Zip:
Street Address:
City: ST: Zip:
Relationship of Petitioner(s) to Respondent:
Spouse Other Relative Legal Guardian (Minor)
Parent Guardian Director of Licensed Service Provider
3. Petitioner alleges that the Respondent meets the criteria for involuntary admission as provided in the
Florida Statutes Section 397.675 in that:
a) Respondent is substance abuse impaired, as evidenced by:
AND
Page 2 of 5
b) Because of such impairment, the Respondent has lost the power of self-control with respect to
substance abuse, as evidenced by:
AND
c)
Respondent has inflicted or is likely to inflict physical harm on himself or others unless
admitted, as evidenced by:
OR,
The Respondent’s refusal to voluntarily receive care is based on judgment so impaired by reason
of substance abuse that the Respondent is incapable of appreciating his/her need for care and making
a rational decision regarding his/her need for care, as evidenced by:
4. Petitioner further alleges: (Petitioner must allege at least one of the following:)
Respondent has been placed under protective custody pursuant to F.S. 397.677 within
the previous 10 days;
Respondent has been subject to an emergency admission pursuant to F.S. 397.679 within the
previous 10 days;
Respondent has been assessed by a qualified professional within 5 days;
Respondent has been subject to involuntary assessment and stabilization pursuant to F.S.
397.6818 within the previous 12 days; or
Respondent has been subject to alternative involuntary admission pursuant to F.S. 397.6822
within the previous 12 days.
5. The Respondent is:
Represented by an attorney:
Name: Phone Number:
Address:
Not represented by an attorney.
Unknown whether Respondent is represented by an attorney.
Page 3 of 5
6. Respondent:
Has assets sufficient to pay attorney fees.
Does not have assets sufficient to pay attorney fees.
Unknown whether the Respondent has assets sufficient to pay attorney fees.
7.
If an assessment was performed on Respondent by a qualified professional, the findings and
recommendations are:
Attached.
As follows:
I/We hereby petition this Court to enter an Order for Involuntary Treatment of the Respondent. I/We
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/We understand that any information in this sworn statement which is not to the best
of my/our knowledge and done in good faith may expose me/us to a penalty for perjury and other possible
penalties under the statutes of the State of Florida.
Under penalties of perjury, I/we declare that I/we have read the foregoing document and that the facts
stated in it are true.
Completed this day of , .
Petitioner(s):
1) Name:
Signature
Address:
Phone No.:
2) Name:
Signature
Address:
Phone No.:
3) Name:
Signature
Address:
Phone No.:
Page 4 of 5
Provide the following identifying information about the person (if known)
County of Residence: Social Security No.: DL#
Date of Birth: Sex: Male Female Race:
Attach a picture of the PERSON if possible. Picture attached: No Yes
Height: Weight: Hair Color: Eye Color:
Distinguishing Features (prominent scars, tattoos, unusual hair color or style, etc.)
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? If yes, describe:
Does the PERSON have any pending criminal charges against him/her? No Yes If yes, describe:
Is the respondent homeless? No Yes **SPECIAL INSTRUCTION TO LOCATE RESPONDENT
Relative or friend contact information for assistance with service:
Name:
Phone #:
Best time to locate for service:
List addresses, areas, businesses, etc. where the respondent might be located:
PHYSICIAN: Name: Phone: ( )
MEDICATIONS: Provide name of medications if known.
Page 5 of 5
STATE OF FLORIDA, COUNTY OF FLAGLER
The foregoing instrument was executed before me on this day of ,
who is personally known
, by
to me
not personally known to me and who has produced
as identification and who
did did not take an oath.
Typed, printed or stamped name of Notary My Commission Expires:
Signature of Notary
OR
SWORN TO AND SUBSCRIBED before me this
day of , .
Tom Bexley
Clerk of the Circuit Court & Comptroller
By:
Deputy Clerk
**NOTE: All information pertaining to the person is confidential and is protected from disclosure
under the authority found in s. 397.501(7), Florida Statutes, and 42 Code of Federal
Regulations, Part 2.
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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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