Adhs/dbhs Form Mh-110 - Petition For Court-Ordered Treatment (Page 2 of 3) in pdf

Adhs/dbhs Form Mh-110 - Petition For Court-Ordered Treatment Page 2

6. The person is entitled to notice of hearing of the petition and may be found at

(location)

7. Petitioner believes the person requires a:

Title 14 guardian;

Conservator;

Title 36 guardian

And requests the Court to order an investigation and report to be made to the Court

regarding this need. Said need exists because:

8. Petitioner believes the proposed person needs the immediate services of a temporary

guardian

conservator and requests that the Court appoint the same

because:

9. Petitioner believes that

address:

, is the

person’s guardian/conservator, who should receive notice of any hearing.

10. A copy of this Petition has been mailed to the Public Fiduciary of

County and (other guardian, if any)

PETITIONER requests that the Court:

1. Set a date for a hearing; and

2. After notice and hearing find that the person is suffering from a mental disorder the result of

which renders him/her dangerous to self or others, persistently or acutely disabled, or

gravely disabled and order a period of treatment, all as set forth in paragraphs (1) and (2)

above.

3. Check if applicable;

Order an independent investigation and report to the Court regarding the need for a Title

14 guardian or conservator or Title 36 guardian.

Appoint the following-named person as temporary guardian and/or conservator of the

person, who Petitioner believes to be a fit and proper person to serve in that capacity;

(Proposed Temporary Guardian/Conservator)

(Relation to Patient)

(Address of Proposed Temporary Guardian/Conservator)

Impose the duties of a Title 36 guardian upon the person’s A.R.S. Title 14 guardian who

DATE

Signature of Petitioner

Medical Director

ADHS/BHS Form MH-110 (9/93)

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Adhs/dbhs Form Mh-110 - Petition For Court-Ordered Treatment Page 2