[Insert caption A from page ______ with the following designation of parties]

THE PEOPLE OF THE STATE OF COLORADO
IN THE INTEREST OF:
Respondent
 

MOTION

 
     It is respectfully shown to this Honorable Court that the requirements of Section 27-10-106, C.R.S., as amended, have been met through the filing of a Petition for Evaluation and the attached Screening Report. It appears that probable cause exists to believe that the respondent is *mentally ill and, as a result of such mental illness, is a danger to others or to himself* *gravely disabled* and that efforts have been made to secure the cooperation of the respondent, who has refused or failed to accept evaluation and treatment voluntarily.
     WHEREFORE, the __________ Attorney of the __________ County of ______ moves that Orders be issued herein:
     1. Placing respondent in ____________________________________________________,
which is a facility designated or approved for seventy-two hour evaluation and treatment.
     2. Directing the Sheriff of the ______ County of ______ to ____________________________________________________
           
           .

		__________Attorney

 

ORDER

 
The above motion is granted and
IT IS SO ORDERED:
DONE IN OPEN COURT THIS__________ (Date)

		Judge

     I, the Clerk of the ______ Court, do certify that the foregoing is a true copy of the said Order entered by the Court on ______ (Date).

		Clerk of the ______ Court

		by

           Deputy Clerk
 

NOTICE TO RESPONDENT

 
     Section 27-10-106 (7), Colorado Revised Statutes, provides that if the evaluation and treatment facility to which you are admitted does not have evaluation and treatment services available on Saturdays, Sundays, or holidays, then the facility may exclude those days in calculating the seventy-two hour detention period.
*Strike between asterisks if inapplicable.

		Form M-8. (6/79) NOTICE OF CERTIFICATION AND CERTIFICATION FOR SHORT-TERM TREATMENT (27-10-107, C.R.S.)

 
 

[Insert caption A from page ______ with the following designation of parties]

IN THE INTEREST OF:
(Name) ____________________
Respondent
Date:______
     The respondent is hereby notified that the following action has been taken pursuant to Section 27-10-107, C.R.S., as amended.
     The respondent has been *detained for seventy-two hour evaluation under the provisions of Section 27-10-105, C.R.S., as amended.* *evaluated under court order pursuant to Section 27-10-106, C.R.S., as amended.*
     The respondent's condition has been analyzed and he has been found to be mentally ill, and, as a result of mental illness, *a danger to others or to himself.* *gravely disabled.*
     *The respondent has been advised of the availability of, but has not accepted, voluntary treatment.* *The respondent has accepted voluntary treatment; however, reasonable grounds exist to believe (s)he will not remain in a voluntary program.*
     Attached hereto is a statement from ____________________, who is on the staff of__________ (facility), setting forth the findings for short-term treatment under certification.
     As a result of the finding for short-term treatment under certification the respondent is hereby certified to __________ (facility) for short-term treatment as of the date first above written and for a period not to exceed three months.

		Professional Person

		Address and Telephone Number

 

NOTICE TO RESPONDENT

 
     You are advised that the law gives you a right to a hearing upon your certification for short-term treatment before a court or jury. In addition to the right to review of this certification you have the right to review by the court, of your treatment or that your treatment be on an out-patient basis. If you wish to take advantage of any of these rights, you should direct a written request to the ______Court of______County, specifying the type of hearing. You may make this request any time that this certification for short-term is in effect.
Strike between asterisks if inapplicable.
 

INSTRUCTIONS ON USE

 
     A copy of the certification within twenty-four hours, must be delivered personally to the respondent, a copy sent to the respondent's attorney, if any, and a copy sent to a person designated by respondent, if any, and the original certification, showing proper delivery and mailing, must be filed with the ______ Court of ______ County, in which county the respondent resided or was physically present immediately prior to being taken into custody. Said filing with the court must be within forty-eight hours, excluding Saturdays, Sundays, and Court Holidays, of the date of certification.
Respondent's Acceptance:
     I, the respondent herein, received a copy of the within certification this ___ day of ______, 20___.

		Respondent

     In the event the respondent will not sign, or cannot sign, the above receipt then give the respondent a copy and acknowledge service as follows:
     I, __________, (print) personally handed to and delivered a true and correct copy of the within certification to the respondent,______, this ___ day of ______, 20___.

		Signature

     I hereby certify that I have sent this day by regular mail, postage prepaid, true and correct copies of the within certification of each of the following persons at the addresses set opposite their respective names:
1. Department of Institutions            4150 South Lowell Boulevard
           Denver, Colorado 80236

		2.

Respondent's Attorney
3.            
Person designated by respondent

		Address

Dated this      

		Signature of person certifying to the mailing

NOTE: If an attorney has not already been appointed, Form M-19 must accompany the Certification submitted to the Court.

		Form M-9. (8/75)

   
 

Facility's Letterhead

 
TO:
(Name and address
of judge and court)
           Notice of Transfer

		Respondent's name

		Court No.

		Date:

     The above named respondent who was certified for ____________________________________________________
____________________ treatment on ____________________________________________________ (date) by
____________________ (facility/professional person) has been transferred to __________ for continuing treatment for the following reasons: ____________________________________________________

		Professional person in charge of treatment

		Address:

		Telephone:

Distribution:
     Court
     Respondent
     Respondent's attorney
     Chart
     Receiving facility

		Form M-10. (8/75)

   
 

Facility's Letterhead

 
TO:
(Name and address
of judge and court)
           Notice of Termination
           of Involuntary Treatment

		Respondent's name

		Court No.

		Date:

     The above named respondent who was certified for ____________________________________________________
by __________ (facility/professional person) on __________, (date) has been discharged and released from care and treatment for the following reasons:

		Professional person in charge of treatment

		Address:

		Telephone:

Distribution:
     Court -- Original
     Respondent
     Respondent's chart
     Respondent's attorney

		Form M-11. (8/75) EXTENDED CERTIFICATION FOR SHORT-TERM TREATMENT (27-10-108, C.R.S.)

 
 

[Insert caption A from page ______ with the following designation of parties]

IN THE INTEREST OF:
(Name) ____________________
Respondent:
Date __________
     The respondent was certified for short-term treatment by ____________________________________________________
__________ (facility/professional person) on __________, (date) and respondent is currently in treatment at ____________________ (facility).
     The respondent's condition has been analyzed and he has been found to continue to be *mentally ill, and, as a result of such mental illness, a danger to others or to himself.* *gravely disabled.* *The respondent has been advised of the availability of, but has not accepted voluntary treatment.* *The respondent has accepted voluntary treatment; however, reasonable grounds exist to believe (s)he will not remain in a voluntary program.*
     Attached hereto is a statement from __________, the professional person in charge of respondent's evaluation and treatment, setting forth the need for an extension of the certification for short-term treatment.
     As a result of the finding of need for continued treatment under certification, the original certification is hereby extended for an additional three months to expire no later than ____________________________________________________.

		Professional person in charge of evaluation

           and treatment

		Address and Telephone Number

*Strike between asterisks if inapplicable.
 

NOTICE TO RESPONDENT

 
     You are advised that the law gives you a right to a hearing upon your extended certification for short-term treatment before a court or jury. In addition to the right of review of this extended certification you have the right to review by the court, of your treatment or that your treatment be on an out-patient basis. If you wish to take advantage of any of these rights, you should direct a written request to the ______ Court of ______ County specifying the type of hearing.      You may make this request at any time that this extended certification for short-term treatment is in effect.
Distribution:
     Original to Court
     Copies to: Respondent, Department of Institutions, Respondent's chart, Respondent's attorney

		Form M-12. (8/75) PETITION FOR LONG-TERM CARE AND TREATMENT (27-10-109, C.R.S.)

 
 

[Insert caption A from page ______ with the following designation of parties]

THE PEOPLE OF THE STATE OF COLORADO
IN THE INTEREST OF:
Respondent
DATE __________
     The above named respondent was originally certified for short-term treatment by ____________________________________________________
__________ (facility/professional person) on __________; (date) and said certification was extended by __________(facility/professional person) on __________, (date) and will expire on __________. The respondent has received short-term treatment continuously for five consecutive months under the provisions of Sections 27-10-107 and 27-10-108, C.R.S., as amended. The respondent is now being treated at __________(facility).
     The respondent continues to be *mentally ill, and, as a result of mental illness, a danger to others or to himself.* *gravely disabled.*
     *The respondent has been advised of the availability of, but has not accepted, voluntary treatment.* *The respondent has accepted voluntary treatment; however, reasonable grounds exist to believe (s)he will not remain in a voluntary program.*
     That ____________________(facility) has been designated or approved by the executive director of the department of institutions to provide respondent with long-term care and treatment.
     Attached hereto is a statement from __________, the professional person in charge of the evaluation and treatment of the respondent, setting forth respondent's need for long-term care and treatment.
*Strike between asterisks if inapplicable.
     As result of the finding of respondent's need for long-term care and treatment, your petitioner prays for a hearing before the court for an order for long-term treatment prior to the above expiration date.

		Professional person in charge of

           evaluation and treatment.

		Address

		Telephone Number

 

NOTICE TO RESPONDENT

 
     You are advised that the law gives you a right to a hearing concerning the within Petition For Long-Term Treatment. The hearing will be before the court unless you request a jury. If you wish to take advantage of your right to a jury you or your attorney must within ten days after receipt of this petition request said jury trial by filing a written request therefor with the ______ Court,
           
           .
 

(address of court)

Respondent's Acceptance:
     I, the respondent herein, received a copy of the within certification this ___ day of ______, 20___.

		Respondent

     In the event the respondent will not sign, or cannot sign the above receipt, then give the respondent a copy and acknowledge service as follows:
     I, __________, (print) personally handed to and delivered a true and correct copy of the within certification to the respondent, __________, this ___ day of ______, 20___.

		Signature

Distribution:
     Original to Court
     Copies to: Respondent, Department of Institutions, Respondent's chart, Respondent's attorney

		Form M-13. (8/75) ORDER FOR LONG-TERM CARE AND TREATMENT (27-10-109, C.R.S.)

 
 

[Insert caption B from page ______ with the following designation of parties]

THE PEOPLE OF THE STATE OF COLORADO
IN THE INTEREST OF:
Respondent
     The Court, *having heard the testimony in this case*, *having the findings of the jury in this case*, determines that the respondent who is currently receiving treatment at ____________________________________________________
__________(facility) is *mentally ill and, as a result of mental illness, a danger to others or to himself*, *gravely disabled,* and in need of long-term care and treatment.
     IT IS ORDERED that the respondent shall receive long-term care and treatment for a period not to exceed six months and for this purpose the Department of Institutions, State of Colorado, shall have custody of respondent for placement with an agency or facility designated by the executive director to provide long-term care and treatment.
     This Order shall expire on __________, (date) unless extended pursuant to statute.
     IT IS FURTHER ORDERED that the clerk of the court forward copies of this Order, duly certified, to the respondent, the institution or agency currently providing care and treatment, the Department of Institutions, and the respondent's attorney.
     Done and signed in open court this __________.

		Judge

*Strike between asterisks if inapplicable.

		Form M-14. (8/75) CERTIFICATE FOR EXTENSION OF LONG-TERM CARE AND TREATMENT (27-10-109 (5), C.R.S.)

 
 

[Insert caption A from page ______ with the following designation of parties]

THE PEOPLE OF THE STATE OF COLORADO
IN THE INTEREST OF:
Respondent
DATE__________
     The above named respondent was last ordered by this court to receive long-term care and treatment on ______, (date) at ____________________________________________________(facility), such order to expire on ______. (date)
     The respondent continues to be *mentally ill and, as a result of mental illness, a danger to others or to himself.* *gravely disabled.*
     *The respondent has been advised of the availability of, but has not accepted, voluntary treatment.* *The respondent has accepted voluntary treatment; however, reasonable grounds exist to believe (s)he will not remain in a voluntary program.*
     This certification for extension of long-term care and treatment is submitted to the court at least thirty days prior to the expiration date of the last order for long-term care and treatment. The undersigned states that an extension of said order is necessary for the care and treatment of the respondent.
           Professional person in charge of
           evaluation and treatment

		Address and telephone number

 

NOTICE TO RESPONDENT AND HIS ATTORNEY, IF ANY

 
     You are notified that you have a right to a hearing upon the requested extension before the court or a jury; however, you must notify the court in writing, specifying the type of hearing you desire, if any.
*Strike between asterisks if inapplicable.
Distribution:
     Original -- Court
     Copies -- Respondent (delivered), Respondent's attorney, Department of Institutions
NOTE ON USE: the court must notify the respondent not less than twenty days before the above expiration date of his right to a hearing on this certification.

		Form M-15. (8/75) NOTICE OF RIGHT TO HEARING (27-10-109 (5), C.R.S.)

 
 

[Insert caption B from page ______ with the following designation of parties]

THE PEOPLE OF THE STATE OF COLORADO
IN THE INTEREST OF:
Respondent
TO THE RESPONDENT ABOVE NAMED AND, ATTORNEY OF RECORD:
     WHEREAS, this Court has entered an order for long-term care and treatment of the respondent, which order is due to expire on __________; and,
     WHEREAS, a certification for extension of long-term care and treatment of the respondent was received by this Court on __________;
     YOU ARE, THEREFORE, NOTIFIED HEREBY that you have a right to a hearing upon this extension before the Court or a jury; however, you must notify the Court in writing specifying the type of hearing within ten days from the date you receive this notice.
     If no written request is received by the Court within the ten day period, the Court will proceed ex parte.
     WITNESS my signature and the seal of said Court this ___ day of ______, 20___.

		Clerk of the ______Court

		By

           Deputy Clerk
(SEAL OF COURT)
 
 
 
 

CERTIFICATE OF MAILING (TO ATTORNEY)

     I certify that on ______, 20 ___, I mailed a copy of the foregoing notice, postpaid, by certified mail, return receipt requested, to ____________________________________________________, (address)
attorney for respondent, at ____________________________________________________.
 

CERTIFICATE OF SERVICE (UPON RESPONDENT)

 
     I certify that on the ___ day of ______, 20___ o'clock ___M., at ______, Colorado, I duly delivered to the above named respondent a copy of the foregoing notice.
NOTE ON USE: This notice should be delivered personally to the respondent and a copy mailed by certified mail, return receipt requested, to the respondent's attorney, if any.

		Form M-16. (8/75) ORDER FOR EXTENSION OF LONG-TERM CARE AND TREATMENT (27-10-109 (5), C.R.S.)

 
 

[Insert caption B from page ______ with the following designation of parties]

THE PEOPLE OF THE STATE OF COLORADO
IN THE INTEREST OF:
Respondent
     The Court, *having heard the testimony in this case,* *having the findings of the jury in this case,* *proceeding ex parte after proper notice was given to respondent and respondent's counsel,* determines that the respondent is *mentally ill and, as a result of mental illness, a danger to others or to himself,* *gravely disabled,* and in need of extended long-term care and treatment.
     IT IS ORDERED that the respondent shall continue to receive long-term care and treatment for a period not to exceed six months, and for this purpose the Department of Institutions, State of Colorado, shall have custody of respondent for placement with an agency or facility designated by the executive director to provide said long-term care and treatment.
     This order shall expire on ______, unless extended pursuant to statute.
     IT IS FURTHER ORDERED that the Clerk of the Court shall forward copies of this order, duly certified, to the respondent, the facility or agency currently providing care and treatment, the Department of Institutions, and the respondent's attorney, if any.
     DONE AND SIGNED IN OPEN COURT on ______.
     BY THE COURT:

		Judge

*Strike between asterisks if inapplicable.
Distribution:
     Original to Court
     Copies to:
     Respondent
     Respondent's attorney, if any
     Facility currently treating respondent;
     Department of Institutions

		Form M-17. (8/75) DISCHARGE ORDER

 
 

[Insert caption B from page ______ with the following designation of parties]

THE PEOPLE OF THE STATE OF COLORADO
IN THE INTEREST OF:
Respondent:
     The Court, *having heard the testimony in this case,* *having the findings of the jury in this case,* determines that the respondent is not *mentally ill and, as a result of mental illness, a danger to others or to himself.* *gravely disabled.*
     IT IS THEREFORE ORDERED that the respondent be discharged, and that the respondent be released from custody forthwith.
     IT IS FURTHER ORDERED that the Clerk of this Court shall forward copies of this order, duly certified, to the respondent, the facility or agency currently providing care and treatment, the Department of Institutions, and the respondent's attorney, if any.
     DONE AND SIGNED IN OPEN COURT on __________.
     BY THE COURT:

		Judge

*Strike between asterisks if inapplicable.
Distribution:
     Original to Court
     Copies to:
     Respondent
     Respondent's attorney, if any
     Facility currently treating respondent
     Department of Institutions

		Form M-18. (8/75) MOTION AND ORDER TO TRANSPORT (27-10-107 (8), C.R.S.)

 
 

[Insert caption A from page ______ with the following designation of parties]

THE PEOPLE OF THE STATE OF COLORADO
IN THE INTEREST OF:
Respondent
     COMES NOW the ______ Attorney of the ______County of ______ and respectfully moves the Court to enter orders herein:
     1. Transporting the above named respondent to ____________________________________________________
____________________(facility).
     2. Directing the Sheriff of ______ County to____________________________________________________
     3.            
____________________. (Other relief requested)
     As grounds for this motion, it is respectfully shown to the Court that the above named respondent has been detained for evaluation and treatment or certified for treatment, and the attached report from __________ states that it is desirable to transfer the respondent to another facility for treatment, and the safety of the respondent or the public requires that the respondent be transported by a sheriff.

		______Attorney

 

ORDER

 
The above motion is granted and IT IS SO ORDERED.
DONE IN OPEN COURT on ______, 20___.

		Judge

		Form M-19. (8/75) APPLICATION FOR REPRESENTATION BY LEGAL COUNSEL

 
NAME OF RESPONDENT ____________________ AGE ______
Last First Middle
ADDRESS ____________________ PHONE NO. ______
Street City State
EMPLOYMENT STATUS:
( ) Yes, at ____________________________________________________
( ) No, last employer ____________________________________________________
( ) No, other member of household is employed at ____________________________________________________
 

RESPONDENT'S                          SOURCE OF                          TOTAL FAMILY

 
 

INCOME                          INCOME                          INCOME

 
 

(if applicable)

 
 

Week $___                          ( ) Employment                          ( ) Welfare                          Week$

 
 

Month $___                          ( ) Social Security                          ( ) Disability                          Month$

 
 

Year $___                          ( ) Unemployment                          ( ) Other                          Year$

 
MONTHLY EXPENSES (Necessities only):
(Rent) or (House Payments) Circle One $      Medical Bills $      
Installment Payments $      Child Support $      
Food and Clothing $      Other $      
MARITAL STATUS:
( ) Single            Name and address of spouse ______
( ) Married            ____________________
( ) Separated            Spouse employed: ( ) Yes ( ) No
( ) Divorced            Name of employer: __________
           Income: Week $___ Month $___ Year $___
 

DEPENDENTS                          LIABILITIES                          ASSETS (include spouse's):

 
 

Children ___                          Major Debts $___                          ( ) Savings $___

 
 

Spouse ___                          ( ) Car $___

 
 

Other ___                          Total Debts $___                          ( ) Realty $___

 
 

Total ___                          ( ) Other $___

 
NAME OF RESPONDENT'S ATTORNEY, IF ANY ____________________________________________________

		Address:

		Phone No.:

     I certify that the information contained herein is true to the best of my knowledge and belief.

		Signature

     The information contained in this application was obtained from the respondent or ____________________________________________________
__________.
     The respondent refused to sign the application and the undersigned has no personal knowledge of the truth of the matter stated herein.

		Name:

		Address:

		Phone No.:

     THIS FORM MUST ACCOMPANY THE CERTIFICATION TO BE SUBMITTED TO THE COURT.

		Form M-20. (8/75) ORDER APPOINTING ATTORNEY (27-10-106 & 107, C.R.S.)

 
 

[Insert caption B from page ______ with the following designation of parties]

THE PEOPLE OF THE STATE OF COLORADO
IN THE INTEREST OF:
Respondent
     The court finds that the respondent's financial condition is as represented by the attached application for representation by appointed counsel.
     The respondent *meets* *does not meet* the criteria established by the legal services agency operating in this jurisdiction and is entitled to appointed counsel *at the expense of the state.*
     *The respondent has requested that the court appoint __________ as his attorney in this matter.*
____________________ is hereby appointed to represent respondent herein this ___ day of ______, 20___ **at the expense of the state pursuant to 27-10-107, C.R.S., as amended.** **Neither this court nor the state shall be responsible for the payment of attorney's fees.**

		Judge

*Strike between asterisks if inapplicable.