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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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(PFIE) August 2012
Template name: MH BA Petition for Involuntary Examination
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PINELLAS COUNTY, FLORIDA
PROBATE DIVISION
IN RE:
UCN: 52 Reference Number:
Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination
I, ,being duly sworn, am filing this sworn statement requesting a court order
Print Name of Petitioner
for the involuntary examination of , (hereinafter referred to as PERSON).
Print Name of Person
This petition and affidavit will be included in the PERSON’S clinical record and may be viewed by the PERSON.
I understand that by filling 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: (Print your full residence address and phone number) Phone: (_____) _________________________
Street Address: ______________________________ City ______________________ST______ ZIP _______
b. I work as a (Occupation) _______________________________Work Phone: (______) ____________________
Work Street Address: _________________________________ City__________________ ST_____ ZIP ______
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 _________________(mm/dd/yyyy) such as domestic violence, trespassing, battery, child abuse or
neglect, Baker Act, etc. as described _________________________________________________________________
_______________________________________________________________________________________________
b. This PERSON has or has not previously made allegations to law enforcement about me or my family
on _______________ (mm/dd/yyyy) such as domestic violence, trespassing, battery, child abuse or
neglect, Baker Act, etc. as described _________________________________________________________________
_______________________________________________________________________________________________
(PFIE) August 2012
Template name: MH BA Petition for Involuntary Examination
Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination (page 2)
4. (Check the 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
______________________________________________ in ________________________________________
Type of Case When
Explain: __________________________________________________________________________________
_________________________________________________________________________________________
5. I am on good terms with the PERSON at the present time. (Check one box) Yes No If “no”, please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
6. I have known the PERSON for ________________________________________________ (how long).
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 serious bodily harm to himself/herself or others. On ________________ at approximately ___________ am/pm
Date (mm/dd/yyyy) Time
I saw the PERSON _____________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
8. Other similar behavior I have personally seen is as follows:_______________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
9. To my knowledge or belief, 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 APPICABLE SECTIONS
10. a. I have attempted to get the PERSON to agree to seek assistance for a mental or emotional problem(s). I 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: ___________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
continued
(PFIE) August 2012
Template name: MH BA Petition for Involuntary Examination
Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination (page 3)
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 that the PERSON is unable to determine for himself/herself, why the examination is necessary because:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
13. I believe that the PERSON suffers from 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/herself because: _________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
16. Can family or close friends now provide enough care to avoid harm to the PERSON? YES NO If not, why?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
continued
(PFIE) August 2012
Template name: MH BA Petition for Involuntary Examination
Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination (page 4)
Provide the following identifying information about the person (if known) if it is determined necessary to take the person into
custody for examination:
County of Residence Social Security No. Date of Birth (mm/dd/yyyy)
Sex Male Female Race: attach a picture of the PERSON if possible Picture 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 patient been violent in the past? No Yes If Yes, describe:
Does the PERSON have any pending criminal charges against him/her? 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: (______) __________________________________
Address: _______________________________________ City: _______________________________ Zip_________
PHYSICIAN Name: _______________________________ Phone: (______) __________________________________
MEDICATIONS Provide name of medications if known.
CASE MANAGEMENT Provide name of case manager or case management agency, if known.
Name: __________________________________ Phone: (_______) __________________________________
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 ______ day of _______________, _________ this ______ day of _______________, _________
Day Month Year Day Month Year
By _______________ who is personally known to me or Ken Burke, Clerk of the Circuit Court and Comptroller
presented _______________________ as identification Pinellas County Florida
________________________________________________ By: ____________________________________
Notary Public – State of Florida Deputy Clerk
My commission expires: Date (mm/dd/yyyy) _____________
A copy of the petition must be attached to an Ex Parte Order for Involuntary Examination and accompany the patient to
the nearest receiving facility.
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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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