IN RE: ___________________________________, Patient

Date of Birth ___________________ SSN: _________________________________

Upon the sworn petition of _____________________________, M.D., the Patient's treating physician, requesting authorization for administration of anti-psychotic medication or electroconvulsive therapy of the Patient, the Court appointed the undersigned attorney at law to represent the interests of Patient in this proceeding, and such attorney attended the hearing and represented the Patient.

The Court finds on the basis of clear and convincing evidence, including evidence presented by __________________________, M.D., a psychiatrist licensed by the Commonwealth of Virginia, that [1], Patient is an adult located within its jurisdiction; [2], there is no guardian or committee reasonably available to consent to the proposed medical treatment; [3], Patient is incapable of making an informed decision to accept or reject such treatment, or is physically or mentally incapable of communicating such decision; [4]; that the Patient is unlikely to become capable of making an informed decision, or of communicating an informed decision within the time required for decision; and [5], that the proposed treatment is in the best interest of the Patient, the Court specifically finding that, in the case of electroconvulsive therapy, the patient is the subject of an order of involuntary commitment heretofore entered and all other reasonable forms of treatment have been considered, and that electroconvulsive therapy is the most effective treatment for the Patient.

It is ORDERED that the specific course of treatment in the Petition is approved and ordered, provided that anti-psychotic medication may not be administered over the Patient's objection except while Patient is subject to an order of involuntary psychiatric hospitalization, and in no event may such medication be administered under this order in excess of one hundred eighty days. Electroconvulsive therapy may not be administered under this order for a period in excess of sixty days.

The treating physician is ORDERED to review and document the appropriateness of the continued admission of anti-psychotic medications not less than every thirty days; the physician and necessary assistants and agents of the physician are authorized to perform the proposed treatment described above, together with all related treatment determined to be medically necessary and incident to the proposed treatment authorized, or which may become necessary in the case of emergency; and the treating physician is ORDERED to report to the Court and to counsel for Patient any change in the condition of the Patient resulting in probable restoration or development of the capacity of Patient to make and to communicate an informed decision prior to the completion of the treatment authorized above.

_____________________________________, Special Justice

Date: ____________________ Time: ____________________

Seen [ ( ) and objected to:]

____________________________, Counsel for Patient

____________________________, Petitioner

Prepared and Copyrighted, 1999, by R. Shawn Majette, VSB 19372