_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
6. The Respondent lacks the capacity to make a reasoned decision about the treatment; and
7. Other less restrictive services were explored and found inappropriate; and
8. The testing and procedures set forth below are essential for the safe and effective
administration of the treatment; and
9. A good faith attempt was made to determine whether the Respondent has executed a Power
of Attorney for Health Care or a Declaration for Mental Health Treatment.
10. Other: ____________________________________________________________________
_________________________________________________________________________
G FOR THE REASONS STATED IN OPEN COURT, THE RESPONDENT IS NOT SUBJECT TO
THE ADMINISTRATION OF AUTHORIZED INVOLUNTARY MEDICATION.
THE COURT’S RULING IS BASED ON FINDINGS OF FACT AND CONCLUSIONS OF LAW AS
STATED ON THE RECORD IN OPEN COURT.
THEREFORE, IT IS HEREBY ORDERED:
G THE PETITION IS GRANTED, AS FOLLOWS:
1. Doctor ______________________________________ (or his/her designee) at
___________________________________________ or a member of the clinical staff of
that facility who is licensed to administer electroconvulsive therapy pursuant to Illinois law
is authorized to administer electroconvulsive therapy as follows:
A. The initial number of treatments to be administered is ____________
G Bilateral G Unilateral G Maximum per week ______
B. Respondent shall also receive the following essential tests and procedures:
2. This Order is in effect for a period not to exceed G 90 G 180 days (405 ILCS 5/2-
107.1(a-5)(5))
3. This matter is continued to _____________at ________ __________________________
(Date) (Time) (Court Location)
for (please specify): _______________________________________________________
2