PS–14

Request to Send a Child or Minor to the
 Department of Mental Health

6/09

Case Number:

In the Juvenile Court of (county):                                                                                                                     County, Alabama

In the matter of (name
of the child/minor):

first  

middle  

last

This form asks the court to send a person under 19 to the Department of Mental Health.

Requested by:                                                                              Agency (if applicable):                                                                        

I declare that the following information about the child/minor is true:
q Name:                                                                                                                                                                                               

first 

middle

last

w Age:                                          years old. 

e Address now:                                                                                                                                                                                  

street 

city

state

Year

zip

Birthdate:                                                                                           

Month

Day

r There is clear and convincing evidence that this child/minor is (check one):

  mentally ill, and
1.  Because of the child/minor’s mental illness, there is a
real danger that s/he may harm him/herself or others.

2. Proof of this danger includes (Describe what the

child/minor did recently that suggests s/he may harm
him/herself or others.):                                                                  
                                                                                                             
 

 mentally retarded, and
1. The person’s mental retardation is not mild, as shown

by the following:                                                                              
                                                                                                               

                                                                                                              

                                                                                                               

                                                                                                               

                                                                                                             
 

                                                                                                               

3.  Mental health treatment is available for this person.
4. This person must be confined to avoid harm to

him/herself or others, such as (describe the harm s/he
may do to him/herself or others.):                                              
                                                                                                             
5. Confinement is the least restrictive available option to

treat this person’s mental illness.

t I ask the court to:

2.

3.

If left in the community, this child/minor is likely to
seriously harm him/herself or others, or
The only care, rehabilitation, and training options for
this child/minor’s are available at the Department of
Mental Health.

–  Find that the child/minor listed in q above is (check one):   mentally ill   mentally retarded, and
–  Have that child/minor committed to the Department of Mental Health.

y I swear that all of the information I provided above is complete and accurate.

Sign below in front of a notary:

                                                                                                                              Date:                                                                                                      

Notary fills out below—
Sworn to and subscribed before me, the undersigned authority,

By (Print name of notary):                                                                                                     

On this date:                                                                                                                              

(Notary’s seal here)

                                                                                                                                                  
Date notary’s commission expires

   Notary signs here

Rev. 6/09
Ala. Code 1975, § 12-15-401, et seq.

 2009 Alabama State Bar