CASE NO. __________
PETITIONER also believes that the Respondent presents an imminent danger or
imminent threat of danger to self, family, or others if not treated because: (state facts to
support belief)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Check one:
☐ Certificate of Physician is attached.
OR
☐ Respondent has refused all requests made by me, the Petitioner, to undergo a
physician’s examination.
Petition is accompanied by:
1.) A security deposit in the amount of $____________.
2.) Guarantee of Payment form.
________________________________ ____________________________________
Signature of Attorney Signature of Petitioner
________________________________ ____________________________________
Name of Attorney (Please Print) Name of Petitioner (Please Print)
Sworn before me and signed in my presence on _____of____________, 20_
_______________________________________________
Notary Public
VERIFICATION OF TREATMENT BY PETITIONER
***A statement from Facility MUST accompany this petition***
___________________________, the petitioner, has arranged for the treatment of
Name of Petitioner
____________________________________ to be facilitated by:
Name of Respondent
__________________________________________________________________________
Name of Treatment Provider
__________________________________________________________________________
Full Address of Treatment Provider (Street, City, State, Zip Code)
FORM 26.0 - PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE
PAGE 2
Effective Date: July 1, 2016