IN THE DISTRICT COURT OF _____________________ COUNTY, STATE OF UTAH IN THE MATTER OF:

NOTICE TO PATIENT OF COMMENCEMENT OF PROCEEDINGS FOR INVOLUNTARY COMMITMENT

TO:_____________________________ Proposed Patient

Notice is hereby given that an Application for the Involuntary Commitment of the above-named proposed patient has been filed with this Court. Said application alleges that the proposed patient is mentally ill and should be involuntarily committed to ______________________________________ based upon the Local Mental Health Authority

following reported facts:______________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Said application also alleges that the said proposed patient has been requested to, but has refused to submit to an examination by a licensed physician or designated examiner. (Cross out if not applicable) Pursuant to statute, the Court will appoint two designated examiners to examine the proposed patient and report to their findings to the Court. Notice of an involuntary commitment hearing, if required, shall be provided to the proposed patient. Dated this _____ day of ____________________, 20_______. ________________________ Court Clerk

DSAMH Form 36-3, Revised 2012

Utah Code Annotated 62A-15-631(4) (2003)

36-3 Notice to Patient of Commencement of Proceedings For ...

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