PETITION FOR INVOLUNTARY/JUDICIAL ADMISSION

This is for the STATE OF ILLINOIS

county of the
admitting
hospital. CIRCUIT COURT FOR THE JUDICIAL CIRCUIT

COUNTY

IN THE MATTER OF
)
) Docket No. Court use only
)
Patient Name )
)
(name of respondent) )

Involuntary
Who is asserted to be a person subject to In-patient admission to a facility and for whom
(judicial/involuntary)
Do not circle
this petition is being initiated by reason of: (Select one or more, if applicable)
Check box must match certificate
Emergency inpatient admission by certificate; (405 ILCS 5/3-600). The Respondent is currently detained in a mental
health facility or hospital; name of facility where detained: .
Only filled out if patient in hospital
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 developmentally disabled; (405 ILCS 5/4-400).

Judicial admission of the developmentally disabled; (405 ILCS 5/4-500).

Developmentally disabled person or an interested person on behalf of a person submitted written objection to
admission; (405 ILCS 5/4-306).

Administrative person; (or person who executed application) failed to authorize continued residence; (405 ILCS 5/4-310).

Person continues to meet standard for judicial admission; (405 ILCS 5/4-611).

These prongs are not used

For an emergency petition A person does not have to be actively suicidal to
be petitioned. Any criteria listed in the first
three prongs apply.
If there is valid criteria seen by other witnesses
and you cannot petition, offer to give said
witness a blank petition.
IL462-2005 (R-4-14) Petition for Involuntary/Judicial Admission
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 I assert that Patient 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; e.g. Self mutilation needing medical attention, hearing voices saying to hurt self or
others, delusions requiring self defense
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;
Unable to judge personal safety, extreme lack of self care, paranoid delusions
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.
Use only if criteria for 1 and 2 are not met and have strong historical evidence
an individual who: is developmentally disabled 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
Do not select this prong
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.
When, who, where,
What happened On 1/1/2000 at 1:01pm, a 25yr old, Caucasian male, known as, John Doe, was found wandering in the road on route 14
Use quotes, if near route 31, wearing only his under wear. He was unable to provide appropriate information or identify himself. He
Possible. Kept repeating "I want to die, I want to kill." He has a history of significant harm to himself when noncompliant with
Identify the harm. treatment. He is at high risk of harm to self and others and cannot care for self and is in need of immediate
Must show clear need hospitalization.
Of hospitalization
Below is a list of all witnesses by whom the facts asserted may be proven (include addresses and phone numbers):

Myself, agency address, agency phone number

Any other witness, address, and phone number Multiple witnesses add credibility
i.e. John Doe's mother (who heard what he said), address, and 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):

If no relative, list friend or neighbor. If unable to obtain any names, explain why:
He refuses to give any info, no prior contact, no one home at his address Don't leave Blank

I do I do not have a legal interest in this matter.

I do I do not have a financial interest in this matter.
I am I am not involved in litigation with the respondent.
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 the petitioner for the following reasons:

If you cannot indicate "I do/am not" state why you are the only one who can complete petition. I.e. "Above information was
witnessed only by me and was provided to prevent harm" ----
Being under arrest is not legal interest

IL462-2005 (R-4-14) Petition for Involuntary/Judicial Admission

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 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.

This is only checked if there

One Certificate of Examination is attached.
is a prepared certificate
Two Certificates of Examination are attached.
If a police officer is involved in transport but not petitioning, please provide this information for petitioner
Did a peace officer detain respondent, take him/her into custody, and/or transport him/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 recipients's request for voluntary or informal
admission prior to adjudication. 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.
Check last box
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 committed or discharged by 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.
If this is not signed, dated, and timed, it is invalid

Date: 2000-01-01 Signed:

Time: This starts the 24 Printed Name:

hour clock Address:
Relationship to Respondent: Work address
Do not write "none"

Police officer Telephone Number: Work phone number

Friend
Family NOTE: a signed petition is a legal document. Subject must be
Paramedic seen by a mental health professional for further assessment

IL462-2005 (R-4-14) Petition for Involuntary/Judicial Admission

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out by the petitioner
 Within 12 hours of admission to the facility under this status I gave the respondent a copy of this Petition (IL462-2005). 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 Developmental Services (IL462-2001) 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 Name:

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 (developmentally disabled) 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 (mentally ill) and if the facility director approves, you may
be admitted to the facility as a voluntary admittee 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 (developmentally disabled) and if the 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 (HIPAA)
(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 HIPAA and the Illinois Mental Health and Development Disabilities Confidentiality Act
[740 ILCS 110].

IL462-2005 (R-4-14) Petition for Involuntary/Judicial Admission

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 A Guardianship and Advocacy Commission is a state agency consisting of three divisions: Legal Advocacy Services, Human
Rights Authority and the Office of the State Guardian. The Commission is located at the following addresses:

East Central Regional Office Peoria Regional Office Rockford Regional Office
2125 S. First Street 401 N. Main Street, Suite 620 4302 N. Main Street, Suite 108
Champaign, IL 61820 Peoria, IL 61602 Rockford, IL 61103
Phone: (217) 278-5577 Phone: (309) 671-3030 Phone: (815) 987-7657
Fax: (217) 278-5588 Fax: (309) 671-3060 Fax: (815) 987-7227

Egyptian Regional Office West Suburban Regional Office Metro East Regional Office
47 Cottage Drive Madden Mental Health Center Holly Bldg., 4500 College
Anna, Illinois 62906-1669 1200 S. First Avenue, P.O. Box 7009 Suite 100
Phone: (618) 833-4897 Hines, IL 60141 Alton, IL 62002
Fax: (618) 833-5219 Phone: (708) 338-7500 Phone: (618) 474-5503
Fax: (708) 338-7505 Fax: (618) 474-5517

North Suburban Regional Office Chicago Regional Office Springfield Regional Office
9511 Harrison Avenue 160 N. La Salle Street 521 Stratton Building
Des Plaines, Illinois 60016 Suite S500 401 S. Spring Street
Phone: (847) 294-4264 Chicago, IL 60601 Springfield, IL 62706
Fax: (847) 294-4263 Phone: (312) 793-5900 Phone: (217) 785-1540
Fax: (312) 793-4311 Fax: (217) 524-0088

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:

Main/Chicago Office Central Illinois Northwestern Illinois Southern Illinois

20 N. Michigan, Ste 300 1 West Old Capitol Plaza, Suite 816 1515 Fifth Avenue, Suite 420 300 E. Main Street, Suite 18
Chicago, Illinois 60602 Springfield, IL 62701O Box 276 Moline, IL 61265 Carbondale, IL 62901
(800) 537-2632 or (217) 544-0464 (309) 786-6868 (618) 457-7930
(312) 341-0022 (800) 758-0464 (800) 758-6869 (800) 758-0559
TTY: (800) 610-2779 TTY: (800) 610-2779 TTY: (800) 610-2779 TTY: (800) 610-2779
Fax: (312) 341-0295 Fax: (217) 523-0720 Fax: (309) 797-8710 Fax: (618) 457-7985

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:

IL462-2005 (R-4-14) Petition for Involuntary/Judicial Admission

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