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Inv14 VOLUNTARY TREATMENT AGREEMENT (West Virginia Supreme Court of Appeals)

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BROWSE WEST VIRGINIA SUPREME COURT OF APPEALS (WV) FORMS

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IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA
IN RE: Involuntary Hospitalization of
Case No. ________- MH -________
___________________________________
RESPONDENT
VOLUNTARY TREATMENT AGREEMENT
[W.Va. Code: §27-5-2(h)]
Now comes on this ______ day of _______________, 2___, the Respondent, in person and by and through his
or her counsel, and submits to the Court this VOLUNTARY TREATMENT AGREEMENT approved by both Respondent and
Counsel for Respondent as reflected by the signature of each to this Agreement. Respondent requests the Court pursuant to West
Virginia Code: § 27-5-2(h) to consider evidence on whether Respondent's circumstances make him or her amenable to outpatient
treatment in a nonresidential or non-hospital setting, to consider whether appropriate outpatient treatment for Respondent is available
in a nonresidential or non-hospital setting, to approve this Agreement, and to enter an Order finding amenability, available appropriate
treatment, and releasing Respondent to outpatient treatment upon the terms and conditions of this Voluntary Treatment Agreement.
The terms and conditions of this Voluntary Treatment Agreement are as follows:
A. Respondent agrees to and will comply with all the terms and conditions set forth in this Voluntary Treatment
Agreement as a condition of release. Respondent acknowledges that in the event he or she fails or refuses to comply with any of the
terms and conditions of this Agreement, the court may order the Respondent taken into custody, brought for hearing before the Court,
and involuntarily committed/hospitalized for examination and treatment pursuant to the provisions of West Virginia Code: § 27-5-3.
B. Respondent may request the court to modify or cancel this Agreement pursuant to the provisions of West Virginia
Code § 27-5-2(h).
C CL MH07 INV 14
C. This Voluntary Treatment Agreement shall have an effective date of _________________________, 2_____, and
shall remain in effect for [insert applicable time period] _____________________________________________,
__________________________________which time period is: [initial appropriate maximum time period]
_____ Not more than six (6) months, inasmuch as the Respondent has not been involuntarily committed in the past two
years.
_____ Not more than two (2) years, since the Respondent has been involuntarily committed in the past two years, to-wit:
[insert date and place of last involuntary commitment] ______________________________________________
_____________________________________________________________________________________.
D. The following treatment provider(s) have been contacted by or on behalf of Respondent and have agreed to provide
Respondent appropriate outpatient treatment or a combination of inpatient/outpatient treatment as more fully described hereinafter in
the terms and conditions of treatment:
Treatment Provider Location Address Phone Number
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
E. As concerns the issue of availability of treatment, the following transportation arrangements have been made/are
available, to make the proposed treatment accessible to Respondent: ___________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
F. As concerns the issue of availability of treatment, the following arrangements have been made/are available, for
payment of the proposed treatment: ________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________________.
C CL MH07 INV 14
G. The specific TERMS AND CONDITIONS OF TREATMENT are as follows:
[Recite specific terms and conditions of the treatment to be offered by the treatment provider and accepted by the Respondent
together with specific obligations of the Respondent in connection with that treatment. Attach additional pages as necessary.]
Treatment pursuant to this Agreement includes [check appropriate box ] ” no days, or ” ________ days [insert number
of days] of VOLUNTARY INPATIENT TREATMENT at the ____________________________________________ mental
health/addiction treatment facility [check appropriate box] ” before or ” during outpatient treatment . Respondent agrees to check
him or herself in to said facility for treatment on the following date(s) [insert date(s)] ______________________________________
or at any time the following described symptoms manifest during outpatient treatment: [describe symptoms] ____________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________.
Respondent agrees to not attempt to check him or herself out of VOLUNTARY INPATIENT TREATMENT during the time
period(s) designated above for such inpatient treatment or for so long as the above-described symptoms remain manifest during the
effective period of this Voluntary Treatment Agreement. Respondent accepts the voluntary inpatient treatment as a condition to the
Court's finding of amenability to outpatient treatment and conditional release of Respondent to outpatient treatment.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
[attach additional pages as necessary]
Submitted, approved by, and given under our hands this ______ day of __________________, 2______.
_____________________________________________________________
RESPONDENT
____________________________________________________________
COUNSEL FOR RESPONDENT
C CL MH07 INV 14
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Inv14 VOLUNTARY TREATMENT AGREEMENT (West Virginia Supreme Court of Appeals)

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Completed 26 July 2020

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