IN THE DISTRICT COURT OF ___________________ COUNTY, STATE OF UTAH ORDER TO DETERMINE EXISTING FACTS IN THE MATTER OF: __________________________ Proposed Patient

Prior to issuing a judicial order, this Court requires the applicant to consult with the appropriate local mental health authority, or directs a mental health professional from that local mental health authority to interview the applicant and the proposed patient to determine the existing facts and report them to the Court.* RECOMMENDED this _____ day of ____________________, 20______

ORDERED this _____ day of _________________________, 20_______ _________________________________ District Court Judge or Mental Health Commissioner

DSAMH Form 36-2, Revised 2012 (Page 1 of 2)

Utah Code Annotated 62A-15-631(2) (2003)

REPORT OF EXISTING FACTS ______________________________________________ Local Mental Health Authority ____________________________

Proposed Patient

At the direction of the Court, consultation with the applicant, or interviews with the applicant and the proposed patient were conducted to determine the existing facts. Based upon the consultation or interviews, I make the following report:_____________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ In the opinion of the undersigned there is sufficient or insufficient cause to warrant further proceedings (circle one). Dated this _____ day of _____________________, 20______. ________________________ Signature

________________________ Title

Instructions: Prior to issuing a judicial order, the court may require the applicant to consult with the appropriate mental health authority, or may direct a mental health professional from that local mental health authority to interview the applicant and the proposed patient to determine the existing facts and report them to the court. 62A-15-631(2) (2003)

DSAMH Form 36-2, Revised 2012 (Page 2 of 2)

Utah Code Annotated 62A-15-631(2) (2003)