FORM MH-404 GC Petition for Authority to Consent to Inpatient MH

• Legal Form Number: FORM MH-404
• Date: 01 January 2014
• 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(s) 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 Rules 24 & 36(B), Ariz. R. Prob. P., Guardian, __________, states:

1. The Court appointed [guardian’s name] as guardian of [ward’s name] on __________.

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.

3. Ward 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 be in need of inpatient mental health care and treatment within the next year. In particular, ____________________.

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

5. Ward is [not represented by an attorney] [represented by (independent)(court-appointed) counsel, ____________, whose address and telephone number are ____________].

6. Based upon Ward’s current [physical] [mental] condition, Ward’s right to retain or obtain a driver license and any other civil right that...