Fillable PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER (State of Ohio)

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PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER (State of Ohio)

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PROBATE COURT OF ________________ COUNTY, OHIO
_____________, JUDGE
IN THE INTEREST OF: ______________________________________________________
CASE NO. __________
PETITION FOR INVOLUNTARY TREATMENT FOR
ALCOHOL AND OTHER DRUG ABUSE
[R.C. 5119.93]
RESPONDENT’S Residence Address: __________________________________________
RESPONDENT’S Current Location (if different): ___________________________________
PETITIONER: ______________________________________________________________
PETITIONER’S Address: _____________________________________________________
States that he/she is:
☐ Spouse; ☐ Relative ____________ ☐ Guardian of the above named Respondent
PETITIONER further states that the name, address, and residence of person related to the
Respondent are (if known)
Parents or guardian: _________________________________________________________
Name and complete address
Spouse: ___________________________________________________________________
Name and complete address
Person having custody of Respondent: ___________________________________________
Name and complete address
Nearest Relative: ____________________________________________________________
Name and complete address
Friend: ____________________________________________________________________
Name and complete address
PETITIONER believes that Respondent is a person suffering from alcohol and/or other drug
abuse because: (state facts to support belief)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
FORM 26.0 - PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE
Effective Date: July 1, 2016
CASE NO. __________
PETITIONER also believes that the Respondent presents an imminent danger or
imminent threat of danger to self, family, or others if not treated because: (state facts to
support belief)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Check one:
☐ Certificate of Physician is attached.
OR
☐ Respondent has refused all requests made by me, the Petitioner, to undergo a
physician’s examination.
Petition is accompanied by:
1.) A security deposit in the amount of $____________.
2.) Guarantee of Payment form.
________________________________ ____________________________________
Signature of Attorney Signature of Petitioner
________________________________ ____________________________________
Name of Attorney (Please Print) Name of Petitioner (Please Print)
Sworn before me and signed in my presence on _____of____________, 20_
_______________________________________________
Notary Public
VERIFICATION OF TREATMENT BY PETITIONER
***A statement from Facility MUST accompany this petition***
___________________________, the petitioner, has arranged for the treatment of
Name of Petitioner
____________________________________ to be facilitated by:
Name of Respondent
__________________________________________________________________________
Name of Treatment Provider
__________________________________________________________________________
Full Address of Treatment Provider (Street, City, State, Zip Code)
FORM 26.0 - PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE
PAGE 2
Effective Date: July 1, 2016
CASE NO. __________
GUARANTEE OF PAYMENT
[R.C. 5119.93(D)(2)]
Pursuant to R.C. 5119.93(D)(2), either the Petitioner or other authorized person (spouse,
relative or guardian) shall guarantee any and all costs and fees for examinations, hearing cost
and treatment for the Respondent for alcohol and other drug abuse as may be herein after
ordered by the Court. The GUARANTEE below shall be completed by either the Petitioner or
other authorized person.
By my signature below, I do hereby assume responsibility for and GUARANTEE PAYMENT
FOR ALL COSTS incurred on behalf of Respondent for all alcohol and other drug abuse
treatment, including, but not limited to, initial examination and transportation costs, as
hereinafter ordered by the Court.
_____________________________________ ____________________
Signature Date
_____________________________________
Name (Please Print)
_____________________________________
Relationship to Respondent (Petitioner, Spouse, Relative or Guardian)
__________________________________________________________________________
Complete Billing Address
Sworn before me and signed in my presence on
________ of ______________, 20__
____________________________________________________
Notary Public
FORM 26.0 - PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE
PAGE 3
Effective Date: July 1, 2016
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PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER (State of Ohio)

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Completed 25 May 2022

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