Fillable STATE OF ILLINOIS (Rev. 4/3/17) IN Respondent ORDER (Administrative Office of the Illinois Courts)

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STATE OF ILLINOIS (Rev. 4/3/17) IN Respondent ORDER (Administrative Office of the Illinois Courts)

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STATE OF ILLINOIS
IN THE ________________JUDICIAL CIRCUIT
__________________COUNTY
(Rev. 4/3/17)
IN
THE MATTER OF:
Respondent
)
)
)
DOCKET NUMBER:___________________
ORDER FOR ADMINISTRATION OF AUTHORIZED INVOLUNTARY TREATMENT
(ELECTROCONVULSIVE THERAPY)
THIS MATTER COMING TO BE HEARD ON THE PETITION OF______________________(Petitioner)
FOR THE ADMINISTRATION OF AUTHORIZED INVOLUNTARY ELECTROCONVULSIVE THERAPY
OF ______________________(Respondent), AND:
G The Petitioner is PRESENT in court.
G The Petitioner is NOT PRESENT in court.
G The Respondent is PRESENT in court.
G The Respondent is NOT PRESENT in court and his/her presence is waived by counsel.
G Notice of this hearing has been provided to the Respondent and all relevant persons pursuant
to 405 ILCS 5/2-107.1.
AFTER A HEARING, THE COURT FINDS BY CLEAR AND CONVINCING EVIDENCE THAT:
G THE RESPONDENT IS SUBJECT TO THE ADMINISTRATION OF AUTHORIZED
INVOLUNTARY ELECTROCONVULSIVE THERAPY, DUE TO THE FOLLOWING:
1. The Respondent has a serious mental illness/developmenta
l disability; and
2. T
he Respondent currently exhibits any of the following (check all that
apply):
G dete
rioration of his or her ability to function, as compared to the Respondent’s ability to
function prior to the current onset of symptoms of the mental illness or developmental
disability for which treatment is presently sought, or
G suffering, or
G threatening behavior; and
3. The illness or disability has existed for a period marked by the continuing presence of such
symptoms set forth in item number 2 above or the repeated episodic occurrence of t
hese
sym
ptoms;
and
4. T
he benefits of the treatment outweigh the harm;
and
5. The Respondent has been advised in writing of the benefits, side effects and risks of the
treatment and of the alternatives to the proposed treatment;
and
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_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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
___________________________________ ____________________________________
G APPEAL RIGHTS GIVEN: G In open court, Respondent present; or G To counsel, with instructions
to advise the Respondent who was not present in court.
G IT IS HEREBY ORDERED THAT THE PETITION IS DENIED AND DISMISSED.
DATED: ____________________________ ENTER: __________________________________
Judge # __________________________________
APPROVED AS TO FORM:
ASSISTANT STATE’S ATTORNEY ATTORNEY FOR THE RESPONDENT
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NOTICE TO THE RESPONDENT AND OTHER PERSONS
IF YOU ARE AFFECTED BY OR INTERESTED IN THIS ORDER, YOU SHOULD KNOW THAT:
1. A FINAL ORDER MAY BE APPEALED.
The court must notify you (the Respondent) either directly or through your counsel of your
right to appeal and, if you are indigent, of your right to have free transcripts and counsel.
If you wish to appeal and cannot obtain counsel, counsel will be appointed for you
pursuant to Section 3-816 of the Mental Health and Developmental Disabilities Code.
2. AN ORDER FOR TREATMENT IS INITIALLY VALID FOR NO MORE THAN 90 DAYS. A
SUBSEQUENT ORDER MAY BE ENTERED FOR AN ADDITIONAL PERIOD OF 90
DAYS.
Thereafter, an order may be valid for up to 180 days.
3. RELATIVES OR FRIENDS MAY TRANSPORT YOU IF YOU HAVE BEEN ADMITTED
BY ORDER.
The court may authorize a relative or friend to transport you to the appropriate facility if
such person can do so safely and humanely.
4. UNWILLINGNESS OR INABILITY OF YOUR PARENT, GUARDIAN, OR PERSON IN
LOCO PARENTIS TO PROVIDE FOR YOUR CARE OR RESIDENCE IS NOT
GROUNDS FOR THE COURT’S REFUSING TO ORDER DISCHARGE.
A petition may be filed under the Juvenile Court Act or Probate Act to ensure appropriate
care and residence.
5. THE COURT MAY MODIFY THIS ORDER IN THE FUTURE.
If your treatment needs change, or if the facility or program cannot meet your needs,
upon petition or other proper method of review, the court may modify this order and enter
a revised order based on the new circumstances.
AT A MINIMUM, THESE PERSONS SHOULD RECEIVE THIS ORDER:
(a) The Respondent;
(b) The Respondent’s attorney;
(c) The director of the facility or program which will administer the treatment, if so
ordered by the Court.
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STATE OF ILLINOIS (Rev. 4317) IN Respondent ORDER (Administrative Office of the Illinois Courts)

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Completed 13 August 2020

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