FORM MH-404 Gc Petition for Authority to Consent to Inpatient Mh

• Legal Form Number: FORM MH-404
• Date: 01 January 2024
• Section: Az Mh Forms Annotated

FORM MH-404

(Attorney's name, State Bar No.)

(Attorney's law firm name)

(Law firm bar number)

(Address)

(Phone number)

(Attorney or firm's e-mail address)

Attorney for: __________

SUPERIOR COURT OF ARIZONA, __________ COUNTY

In the Matter of the Guardianship of [and Conservatorship for]: an Adult. NO. __________ PETITION FOR AUTHORITY TO CONSENT TO INPATIENT MENTAL HEALTH CARE AND TREATMENT INCLUDING PLACEMENT

Pursuant to A.R.S. § 14-5312.01(B) and Rule 47(a), Ariz. R. Prob. P., Guardian, __________, states:

1. The Court appointed __________ as guardian on (date).

2. [The current appointment order does not authorize Guardian to consent to inpatient mental health care and treatment including placement in a level one inpatient mental health care and treatment facility.] [Guardian's authority to consent to inpatient mental health care and treatment including placement in a level one inpatient mental health care and treatment facility has expired.]

3. (Subject person's name) is incapacitated as defined by A.R.S. § 14-5101(1) as a result of a mental disorder as defined by A.R.S. § 36-501(25) and is likely to need inpatient mental health care and treatment within the next year. In particular, ____________________.

4. The evaluation by [name of psychiatrist or psychologist] supports this petition and [is filed] [will be filed] as a confidential document.

5. (Subject person's name) is [not represented by an attorney] [represented by counsel, ____________, whose address and telephone number are ____________].

[Guardian requests that the Court appoint an attorney to represent (subject person's name) in these proceedings pursuant to A.R.S. § 14-5312.01(K).]

Guardian requests that, after notice and hearing, the Court:

A. Find by clear and convincing evidence that (subject person's name) is an incapacitated person as defined by A.R.S. § 14-5101(1) as a result of a mental disorder as defined by A.R.S. § 36-501(25) and is likely to need inpatient mental health care and treatment within the next year.

B. Grant Guardian the authority under A.R.S. § 14-5312.01(B) to consent for (subject person's name) to receive inpatient mental health care and treatment, including placement in a level one behavioral health facility licensed by the Arizona Department of Health Services and medical, psychiatric, and psychological treatment associated with the placement.

D. Enter other orders as the Court deems appropriate.

DATED...