Fillable Petition and Affidavit Seeking Involuntary Substance Abuse Assessment (Flagler County Clerk of the Circuit Court & Comptroller)

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Petition and Affidavit Seeking Involuntary Substance Abuse Assessment (Flagler County Clerk of the Circuit Court & Comptroller)

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Page 1 of 6
IN THE CIRCUIT COURT OF THE SEVENTH JUDICIAL
CIRCUIT IN AND FOR FLAGLER COUNTY, FLORIDA
IN RE: CASE NO:
Respondent
Petition and Affidavit Seeking Involuntary Substance Abuse Assessment Stabilization
I, , being duly sworn, am filing this sworn statement
requesting a court order for the involuntary assessment of
(hereinafter referred to as PERSON).
The PERSON is 18 years of age or older? Yes or No AGE 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 hospital or licensed
substance abuse facility for assessment and stabilization.
I SWEAR that the answers to the following questions are given honestly, in good faith and to the best of my
knowledge.
1. a. Petitioner #1 - I live at: (Full Residence Address & Phone Number with area code)
Street Address: City:
State: Zip: Phone: ( )
Petitioner #2 - I live at: (Full Residence Address & Phone Number with area code)
Street Address: City:
State: Zip: Phone: ( )
Petitioner #3 - I live at: (Full Residence Address & Phone Number with area code)
Street Address: City:
State: Zip: Phone: ( )
b. 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:
2. I have the following relationship with the PERSON:
3. I am on good terms with the PERSON at the present time. Yes or No If “no” please explain:
Page 2 of 6
4. (Check the boxes that apply)
a. I or a family member have or have not previously made allegations to law enforcement
involving this PERSON on (Date) such as domestic violence, trespassing, battery,
child abuse or neglect, Baker Act, neighborhood disputes,. If allegations have been made, describe:
b. This PERSON has or has not previously made allegations to law enforcement about
me or my family on (Date) such as domestic violence, trespassing, batter, child
abuse or neglect, Baker Act, neighborhood disputes, etc. If allegations have been made, describe:
c.
This PERSON
has or has not previously (or currently) been involved in criminal or
delinquency charges.
5. (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 (Type of case) in (When).
Explain:
6. I have known the PERSON for (how long?)
a. The PERSON has only recently displayed behavior related to substance abuse.
b. The PERSON has, over a period of time, had a substance abuse problem. Specify how long:
Page 3 of 6
CHECK AND COMPLETE THE FOLLOWING ONLY IF THE SECTION APPLIES TO THIS CASE:
7. I believe that the PERSON is substance abuse impaired (defined in F.S. 397.311(18) as a condition
involving the use of alcoholic beverages or any psychoactive or mood-altering substance in such a manner
as to induce mental, emotional, or physical problems and cause socially dysfunctional behavior) or has a
co-occurring mental health disorder. If checked, explain why (i.e., observation, related knowledge, etc.).
8. I believe that because of such impairment or disorder, the PERSON has lost the power of self-control
with respect to substance abuse. If checked, explain why (i.e. observation, related knowledge, etc.).
9. I believe the PERSON is in need of substance abuse services by reason of substance abuse impairment
and he or she is incapable of appreciating his or her need for services and of making a rational decision in
that regard (a mere refusal to receive services is not enough to constitute lack of judgment). If checked,
explain why (i.e. observation, related knowledge, etc.).
10. I believe that without care or treatment, he or she is likely to suffer from neglect or refuse to care for
himself or herself and that such neglect or refusal poses a real and present threat of substantial harm to
his or her well-being. If checked, explain why (i.e., observation, related knowledge, etc.).
11. I do not believe that such harm may be avoided through the help of willing family members or friends
or the provision of other services. If checked, explain why (i.e., observation, related knowledge, etc.).
Page 4 of 6
12.
I believe there is substantial likelihood that the Person has inflicted, or threatened to or attempted to
inflict, or unless admitted, is likely to inflict, physical harm on himself, herself, or another. If checked,
explain why (i.e., observation, related knowledge, etc.).
13. a.
I have attempted to get the PERSON to seek assistance for a substance abuse problem(s) as
follows:
b.
I did not try to get the PERSON to agree to voluntary assessment or treatment because:
c.
The PERSON refused a voluntary assessment or treatment because:
14.
I have made arrangements for the PERSON to be admitted to
(Facility) located at:
for voluntary assessment and stabilization.
15.
The name of the PERSON’s attorney (if any) is:
16.
PERSON can or
cannot afford an attorney. If not, petitioner requests the court to appoint
an attorney to represent the PERSON.
17.
Does the PERSON have a legal guardian?
Yes
No Unknown
18.
Is there a pending petition to determine the PERSON’S capacity and to appoint a guardian?
Yes
No
Unknown
If yes to either question 17 or 18 above, provide the name, address and phone number of the
current or proposed guardian.
Name:
Phone:
(Address),
(City),
(State),
(Zip Code)
Page 5 of 6
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:
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:
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:
Does the PERSON have any pending criminal charges against him/her? No Yes If yes, describe:
Is the respondent homeless? No Yes **SPECIAL INSTRUCTIONS TO LOCATE RESPONDENT
PHYSICIAN: Name: Phone: ( )
MEDICATIONS: Provide name of medications if known.
Distinguishing Features (prominent scars, tattoos, unusual hair color or style, etc.)
DL#:
Relatative or friend contact information for assistance with service:
Name:
Phone #
Best time to locate:
List addresses, areas, businesses, etc. where the respondent might be located:
Page 6 of 6
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 #1:
Signature of Affiant/Petitioner #2:
Signature of Affiant/Petitioner #3:
SWORN TO AND SUBSCRIBED before me OR SWORN TO AND SUBSCRIBED before me
This day of, This day of ,
by who is personally known
to me or presented as identification
Tom Bexley, Clerk of the Circuit Court & Comptroller
By:
Notary Public – State of Florida Deputy Clerk
My Commission expires:
A copy of this petition must be attached to an Order for Involuntary Substance Abuse Assessment and
Stabilization and accompany the PERSON to a licensed hospital or substance abuse facility that has agreed to
accept the PERSON.
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Petition and Affidavit Seeking Involuntary Substance Abuse Assessment (Flagler County Clerk of the Circuit Court & Comptroller)

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Completed 22 July 2021

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