In the Circuit Court, ______ Judicial Circuit

IN THE CIRCUIT COURT, ______JUDICIAL CIRCUIT, IN AND FOR ______COUNTY, FLORIDA

IN RE: ______Case No.: ______

ORDER REQUIRING EVALUATION FOR INVOLUNTARY OUTPATIENT PLACEMENT

THIS MATTER came to be heard on ______, pursuant to s. 394.467, F.S., on petition for involuntary inpatient placement of the above-named person and the court being advised in the premises, finds as follows:

1. The above-named person does not meet the criteria for involuntary inpatient placement in a mental health treatment or receiving facility. 2. The above-named person is 18 years of age or older, has a mental illness, and has a history of lack of compliance with treatment for mental illness. 3. The above-named person is unlikely to survive safely in the community without supervision; this finding is supported by testimony of ______as to his/her clinical determination. 4. The above-named person has: A. At least twice within the preceding 36 months been involuntarily admitted to a receiving or treatment facility as defined in s.394.455, or received mental health services in a forensic or correctional facility, or B. Engaged in or attempted to engage in one or more acts of serious violent behavior toward self or others within the preceding 36 months. 5. The above-named person is, as a result of mental illness, unlikely to voluntarily participate in recommended treatment and has either refused voluntary placement for recommended treatment after sufficient and conscientious explanation and disclosure of the purpose of placement, or is unable to determine whether placement is necessary. 6. In view of the person’s treatment history and current behavior, the person is in need of involuntary outpatient placement in order to prevent a relapse or deterioration that would be likely to result in serious bodily harm to the person or others, or a substantial harm to the person’s well-being through neglect or refusal to care for self as set forth in s. 394.463(1); 7. It is likely that the person will benefit from involuntary outpatient placement. All available less restrictive alternatives that would offer an opportunity for improvement of his or her condition are either inappropriate or unavailable.

Whereupon, IT IS ORDERED

1. That the above-named person be discharged this date from any involuntary inpatient placement and treatment for mental illness. 2. That the above-named person shall be evaluated by ______located at ______for involuntary outpatient placement within ______days of the date of this hearing.

DONE AND ORDERED in Chambers at ______County, Florida, this __ day of ______, 20____.

______Printed Name of Circuit Court Judge Signature of Circuit Court Judge

See s. 394.4655(6)(c), Florida Statues CF-MH 3115, Feb 05 (Recommended Form) BAKER ACT