The information that I am giving about completing a petition is Illinois clinicians only. Each state is different in their processes for petitioning a person. Below is the Illinois petition for involuntary or judicial admission. I am frequently asked for help in completing a petition for involuntary admission by other counselors who don’t work in a hospital setting and don’t have to write them often, as well as by those who transport patients, such as EMTs or police officers. So often, our hospital receives petitions that are not properly completed, either boxes are not checked or details about the person’s need for involuntary admission is vague. Either way, this poses as a problem, as the petition is a legal document. Here are some general rules/info: 1. Petitions need to be completed by the person who is a witness to the petitionable statement or action, that means all pages need to be written in one handwriting. Often parts are filled out by several people-this is not legal. 2. Petitions are only valid for 24 hours. You cannot petition a person for something they did or said more than 24 hours ago. 3. If a person has made a suicidal or homicidal gesture, threat, statement with intent, or is not caring for self, these may all be signs that a person may need inpatient treatment. If you feel that they are not safe this is may be an indication for inpatient treatment. 4. A petition is filled out by a witness (ie your client makes a suicidal statement with a definitive plan-this makes you the witness). You complete a petition. The petition does not become valid UNLESS your client decides that s/he does not want to sign into the hospital. At that point, a mental health counselor or clinician will sign the final pages of your petition, which makes it valid. If your client agrees with inpatient treatment and signs in at the hospital, the petition does not become valid. Below is the newest version of the Illinois Petition for Involuntary or Judicial Admission. I have highlighted what should be completed and given some notes about each section. Feel free to ask more questions! And again, this is for Illinois, each state is different. PETITION FOR INVOLUNTARY/JUDICIAL INPATIENT ADMISSION STATE OF ILLINOIS CIRCUIT COURT FOR THE JUDICIAL CIRCUIT COUNTY IN THE MATTER OF ) Docket No. ) ) FULL NAME ) (name of respondent) Who is asserted to be a person subject to INVOLUNTARY In-patient admission to a facility and for whom this petition (judicial/involuntary) is being initiated by reason of: (Select one or more, if applicable) [X ] Emergency inpatient admission by certificate; (405 ILCS 5/3-600) The Respondent is currently detained in a mental health facility or hospital; name of institution where detained:COMPLETE IF YOU KNOW THE HOSPITAL WHERE CLIENT WILL BE ADMITTED, OTHERWISE LEAVE BLANK. [ ] Inpatient admission by court order; (405 ILCS 5/3-700). [ ] Voluntary admittee submitted written notice of desire to be discharged and two Certificates are attached to/submitted with this petition; (405 ILCS 5/3-403). [ ] Voluntary admittee failed to reaffirm a desire to continue treatment and two Certificates are attached to/submitted with this petition; (405 ILCS 5/3-404). [ ] Person continues to be subject to involuntary admission on an inpatient basis; (405 ILCS 5/3-813). [ ] Emergency admission of the mentally retarded; (405 ILCS 5/4-400). [ ] Judicial admission of the mentally retarded; (405 ILCS 5/4-500). [ ] Developmentally disabled client or an interested person on behalf of a client submitted written objection to admission; (405 ILCS 5/4-306). [ ] Administrative client (or person who executed application) failed to authorize continued residence; (405 ILCS 5/4-310). [ ] Client continues to meet standard for judicial admission; (405 ILCS 5/4-611). Page 1 of 5 REVISED 2/28/2011 I assert that FULL NAME is: (check all that apply) [ ] a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed; [ ] a person with mental illness who: because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm without the assistance of family or others, unless treated on an inpatient basis; [ ] a person with mental illness who: refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration and is reasonably expected, after such deterioration, to meet the criteria of either paragraph one or paragraph two above; [ ] an individual who: is mentally retarded and unless treated on an in-patient basis is reasonably expected to inflict serious physical harm upon himself or herself or others in the near future; and/or [ X ] in need of immediate hospitalization for the prevention of such harm. I base the foregoing assertion on the following (State in detail the signs and symptoms of mental illness displayed by the Respondent. Include prior diagnosis, treatment and hospitalizations. Describe any threats, behavior or pattern of behavior which support your complaint. Include personal observations that lead to your belief the Respondent is subject to involuntary admission. If additional space needed please attach a separate page or pages): HERE YOU NEED THE DATE, TIME AND LOCATION OF INCIDENT. MAKE SURE TO WRITE PERSON’S NAME. ONLY THE WITNESS TO THE INCIDENT OR STATEMENTS THAT ARE MADE BY CLIENT CAN WRITE THE PETITION. USE DIRECT QUOTES FROM CLIENT IF POSSIBLE IF THREATS OF SUICIDE OR HOMICIDE ARE MADE. LIST WHY PERSON IS A HARM TO THEMSELVES OR OTHERS. IF THEY ARE NOT ABLE TO CARE FOR THEMSELVES, LIST WHY, I.E. NOT PERFORMING ADLS, NOT EATING OR SLEEPING, NOT SHOWERING OR BRUSHING TEETH, ISOLATING, NOT GOING TO WORK ANYMORE, ETC. MAKE SURE TO END STATEMENT WITH ____ IS IN NEED OF IMMEDIATE HOSPITALIZATION TO PREVENT HARM TO SELF OR OTHERS. Below is a list of all witnesses by whom the facts asserted may be proven (include addresses and phone numbers): YOUR NAME, WORK ADDRESS, AND WORK PHONE NUMBER Listed below are the names and addresses of the spouse, parent, guardian, or substitute decision maker, if any, and close relative or, if none, a friend of the respondent whom I have reason to believe may know or have any of the other names and addresses. If names and addresses are not listed below, I made a diligent inquiry to identify and locate these individuals and the following describes the specific steps taken by me in making this inquiry (additional pages may be attached as necessary): LIST EMERGENCY CONTACT NAME, ADDRESS, AND PHONE NUMBER [ ] I do [X] I do not have a legal interest in this matter. [ ] I do [X] I do not have a financial interest in this matter. [ ] I am [X] I am not involved in litigation with the respondent. Page 2 of 5 [ ] Although I have indicated that I have a legal or financial interest in this matter or that I am involved in litigation with the respondent, I believe it would not be practicable or possible for someone else to be in petitioner for the following reasons: [ ] No certificate was attached with this petition because no physician, qualified examiner, or clinical psychologist was immediately available or it was impossible after diligent effort to obtain a certificate. However: I believe, as a result of my personal observation, that the respondent is subject to involuntary inpatient admission. A diligent effort was made to obtain a certificate; but no physician, qualified examiner or clinical psychologist could be found who has examined or could examine the respondent; and a diligent effort has been made to convince the respondent to appear voluntarily for examination by a physician, qualified examiner or clinical psychologist, or I reasonably believe that effort would impose a risk of harm to the respondent or others. [X] One Certificate of Examination is attached. [ ] Two Certificates of Examination are attached. Did a peace officer detain respondent, take him or her into custody, and/or transport him or her to the mental health facility? [ ] No [ ] Yes; If yes, the peace officer MAY complete the petition or if the petition IS NOT COMPLETED by the peace officer transporting the person, the following information MUST be entered: Transporting Officer’s Name: Badge Number: Employer: The petitioner can request to be notified if the facility director approves the recipient’s request for voluntary or informal admission prior to adjudication. (405 ILCS 5/3-801) The petitioner may also request to be notified of the recipient’s discharge under section 3-902(d) of the Mental Health and Developmental Disabilities Code. Failure to indicate a choice will be treated as a decision NOT to be notified. [ ] If the individual requests and is approved for voluntary or informal admission prior to adjudication, I wish to be notified using the contact information supplied below. (Hospital staff use form IL462-2203 for notification purposes). [ ] If the individual is discharged by the court, I wish to be notified using the contact information supplied below. (Hospital staff use form IL462-2208M for notification purposes). [ ] I do not wish to be notified in either of the two situations described above. The petitioner has made a good faith attempt to determine whether the recipient has executed a power of attorney for health care under the Powers of Attorney for Health Care Law or a declaration for mental health treatment under the Mental Health Treatment Preference Declaration Act and to obtain copies of these instruments if they exist. I have read and understood this petition and affirm that the statements made by me are true to the best of my knowledge. I further understand that knowingly making a false statement on this Petition is a Class A Misdemeanor. Date: TODAYS DATE Signed: YOUR SIGNATURE Time: TIME OF PETITION Relationship to Respondent Printed Name: YOUR NAME YOUR RELATIONSHIP TO CLIENT Address: YOUR WORK ADDRESS Telephone Number: YOUR WORK PHONE NMBR Page 3 of 5 Within 12 hours of admission to the facility under this status I gave the respondent a copy of this Petition (MHDD-5). I have explained the Rights of Admittee to the respondent and have provided him or her with a copy of it. I have also provided him or her with a copy of Rights of Individuals Receiving Mental Health and Developments Services (MHDD-1) and explained those rights to him or her (405 ILCS 5/3-609) Date/Time of Admission Signed: To Mental Health Facility/Psychiatric Unit Printed Named: Title: ______ RIGHTS OF ADMITTEE 1. If you have been brought to this facility on the basis of this petition alone, you will not be immediately admitted, but will be detained for examination. You must be examined by a qualified professional within 24 hours or be released. 2. When you are first examined by a physician, clinical psychologist, qualified examiner, or psychiatrist, you do not have to talk to the examiner. Anything you say may be related by the examiner in court on the issue of whether you are subject to involuntary or judicial admission. 3. At the time that you have been certified you will be admitted to the facility and a copy of the petition and certificate will be filed with the court. A copy of the petition shall also be given to you 4A. If you are alleged to be subject to involuntary admission (mentally ill) you must also be examined within 24 hours excluding Saturdays, Sundays, and holidays by a psychiatrist (different from the first examiner) or be released. If you are alleged to be subject to involuntary admission the court will set the matter for a hearing. 4B. If you are alleged to be subject to judicial admission (mentally retarded) the court will set a hearing upon receipt of the diagnostic evaluation which is required to be completed within 7 days. 5A. If you are alleged to be subject to involuntary admission (mental ill) and if the facility director approves, you may be admitted to the facility as a voluntary admitted upon your request any time prior to the court hearing. The court may require proof that voluntary admission is in your best interest and in the public interest. 5B. If you are alleged to be subject to judicial admission (mentally retarded) and if they facility director approves, you may decide that you prefer to admit yourself to the facility rather than have the court decide whether you ought to be admitted. You may make the request for administrative admission at any time prior to the hearing. The court may require proof that administrative admission is in your best interest and the public interest. 6. You have the right to request a jury. 7. You have the right to request an examination by an independent physician, psychiatrist, clinical psychologist, or qualified examiner of your choice. If you are unable to obtain an examination, the court may appoint an examiner for you upon your request. 8. You have the right to be represented by an attorney. If you do not have funds or are unable to obtain an attorney, the court will appoint an attorney for you. 9. You have the right to be present at your court hearing. 10. As a general rule, you do not lose any of your legal rights, benefits, or privileges simply because you have been admitted to a mental health facility (see your copy of the rights of Individuals)”. However, you should know that persons admitted to mental health facilities will be disqualified from obtaining Firearm Owner’s Identification Cards, or may lose such cards obtained prior to admission. 11. Information about the health care services you receive at a mental health or developmental disabilities facility is protected by privacy regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPPA) (P.O. 104-191) at 45 CFR 160 and 164. Your personally identifiable health information will only be used and/or released in accordance with HIPPA and the Illinois Mental Health and Development Disabilities Confidentiality Act [740 ILCS 110]. Page 4 of 5 A GUARDIANSHIP AND ADVOCACY COMMISSION IS A STATE AGENCY WHICH CONSISTS OF THREE DIVISIONS: LEGAL ADVOCACY SERVICES, HUMAN RIGHTS AUTHORITY AND THE OFFICE OF THE STATE GUARDIAN. THE COMMISSION IS LOCATED AT: Egyptian Regional Office Peoria Regional Office #7 Cottage Drive 5407 North University, Suite 7 Anna, Illinois 62906 Peoria, Illinois 61614 618/833-4897 309/693-5001 East Central Regional Office Rockford Regional Office 423 South Murray Road 4302 North Main Street Rantoul, Illinois 61866-2125 Rockford, Illinois 61103 217/892-4611 815/987-7657 North Suburban Regional Office West Suburban Regional Office 9511 Harrison Avenue, FA101 P.O. Box 7009 Des Plaines, Illinois 60016 Hines, Illinois 60141-7009 847/294-4264 708/338-7500 Metro East Regional Office Pine Cottage 4500 College Avenue Alton, Illinois 62002 618/462-4561 Equip for Equality, Inc. is an independent, not-for-profit organization that administers the federal protection and advocacy system to people with disabilities in Illinois. Equip for Equality, Inc., provides self-advocacy assistance, legal services, education, public policy advocacy, and abuse investigations. The offices are located at: Northeastern Regional Office West/Central Region 20 N. Michigan, Ste 300 235 S. 5th Street Chicago, IL. 60602 PO Box 276 800/537-2632 or 312/341-0022 800/758-0464 (Voice/TTY) 217/544-0464 TTY: 800/610-2779 Se habla espanol Northwestern Region 1612 Second Avenue PO Box 3753 Rock Island, IL 61204 800/758-6869 (Voice/TTY) 309/786-6868 Website: www.equipforequality.org I certify that I provided respondent with a copy of this form. [ ] English [ ] Spanish [ ] Other Specify language: on Time: Signature: Title: Printed Name: Page 5 of 5
Maureen Werrbach is a counselor who works at a hospital and provides clinical assessments in the areas of mental health and substance abuse.