IN RE: ___________________________________, Patient

Date of Birth ___________________ SSN: _________________________________

Petitioner, ________________________________________, M.D., a psychiatrist licensed by the Commonwealth of Virginia, alleges that the Patient is an adult located within the jurisdiction of this Court; Patient is subject to an order of involuntary commitment entered pursuant to Va. Code Ann. §37.1-67.3, or is detained under an order pursuant to Va. Code Ann. §37.1-67.1 et seq. to obtain such order; no guardian or committee of the Patient is reasonably available to consent to administration of anti-psychotic medication or electroconvulsive therapy; Patient is incapable of making an informed decision to accept or reject such treatment, or is physically or mentally incapable of communicating such decision; Patient is unlikely to become capable of making an informed decision, or of communicating an informed decision within the time required for decision; and the proposed treatment is in the best interest of the Patient, it being alleged in the case of electroconvulsive therapy, all other reasonable forms of treatment have been considered, and that electroconvulsive therapy is the most effective treatment for Patient.

The proposed TREATMENT PLAN is:

[ ] that the following anti-psychotic medication, ____________________________________ ________________________________________________, be administered to the Patient commencing ____________________, for a period not in excess of __________ days [LIMIT: 180 DAYS].

[ ] that electroconvulsive therapy be administered a total of _________ treatment(s) over the course of _____________ days, commencing __________________ [LIMIT: 60 DAYS].

Petitioner acknowledges that Petitioner must review and document the appropriateness of the continued admission of anti-psychotic medications not less than every thirty days, and Petitioner must report to the Court and to Patient's counsel any change in the person's condition resulting in probable restoration or development of the Patient's capacity to make and to communicate an informed decision prior to the completion of the treatment requested above.

I delivered a copy of this Petition to the Patient today. I informed the Patient and the following persons of the following hearing date and time: Date: _________________ // Time: _______________.

_____________________________, M.D. (Print Name: ___________________)

Telephone: _________________ Pager Number: ________________

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