Superior Court Of The State Of California For The County Of Los Angeles printable pdf download

Superior Court Of The State Of California For The County Of Los Angeles

(TYPE/PRINT)

Hospital:_______________________________

(Name)

Unit:__________________________________

(Name or Number)

Interpreter Required: NO

YES ________________

(Circle One)

(Language)

SUPERIOR COURT OF THE STATE OF CALIFORNIA

FOR THE COUNTY OF LOS ANGELES

In the Matter of

)

(RIESE PETITION)

)

PETITION AND DECLARATION

)

REGARDING CAPACITY TO GIVE

)

INFORMED CONSENT TO MEDICATION

)

WIC § 5332(b)

)

___(Patient’s Name)

)

BY FAX

Petitioner, _________________________________________________ , declares that:

(Please type/print Treating Physician’s Name)

1. On ___________________, I evaluated ________________________________________

(Date)

(Patient's Name)

at____________________________________________________________.

(Hospital Name)

2. This patient is currently being held at the above facility under Welfare and Institutions Code

Section(s): 5150 (72 hour hold) [ ], 5250 (14 day hold) [ ], 5260 (additional 14 day hold)[ ],

5270.15 (additional intensive treatment 30 day hold)[ ], 5300 (180 day post certification)[ ].

3. This patient is presently showing symptoms of a mental disorder known as:

_____________________________________________________________________________

These symptoms are:____________________________________________________________

_____________________________________________________________________________

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Rev. 9/6/13

Superior Court Of The State Of California For The County Of Los Angeles