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Here is the text we could read:

 
Name 
 
Address 
 
City, State, Zip 
 
Phone 

 
Email 

 

 

 
 
 
 
 
 

If you do not respond to this 
document within applicable time 
limits, judgment could be entered 
against you as requested. 

 
Check your email. You will receive information and 
documents at this email address. 
 

I am   [  ]  Petitioner    

[  ]  Petitioner’s Attorney   (Utah Bar #:__________) 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

In the matter of essential treatment for 

Petition for Essential Treatment and 
Intervention 
(Utah Code 62A-15-1203) 

_____________________________________ 
Respondent 

_______________________________ 
Case Number 

_______________________________ 
Judge 

1. 
 

Venue 
I am filing my petition with this court because respondent lives in this county or is 
present in this county. 

2. 

Information about respondent 

Legal name 

Date of birth  
(if known) 

Social security number  
(if known) 

Address and current 
location  
(if known) 

 

 

 

 

Form 1001ICF Approved October 17, 
2017 / Revised February 8, 2021 

Petition for Essential Treatment and Intervention 

Page 1 of 4 

 

 

3. 

Petitioner’s relationship to respondent 
Respondent is my:  

[  ]  spouse  
[  ]  parent  
[  ]  stepchild  

[  ]  grandchild  
[  ]  child 
[  ] sibling  

4. 

Guardian for respondent 
Respondent 

[  ]  does not have a legal guardian 

[  ]  has a legal guardian, and the guardian’s name and address is (if known): 

Criteria for essential treatment and intervention 
Respondent is suffering from a substance use disorder that, if not treated, 
presents a serious harm to self or others (Explain. Include information about any previous 
evaluation or treatment.): 

espondent can reasonably benefit from the essential treatment (Explain.): 

Form 1001ICF Approved October 17, 
2017 / Revised February 8, 2021 

Petition for Essential Treatment and Intervention 

Page 2 of 4 

ame 

ddress 

ity, State, Zip 

hone number 

ourt name 

ase number 

  N

  A

  C

  P

    C

  C

    R

   

 

5. 

 

 

 

Respondent is unlikely to substantially benefit from a less-restrictive alternative 
treatment (Explain.): 

6. 

Essential treatment 
Respondent can receive essential treatment at the following local substance 
abuse authority or approved treatment facility or program (List at least one local 
substance abuse authority or approved treatment facility or program.): 

7. 

[  ]  Proof of health insurance  

I am attaching proof of health insurance to provide for respondent's 
essential treatment. 

8. 

The guarantor, identified below, agrees to pay all treatment costs beyond those 
covered by the respondent’s health insurance policy for all treatment ordered for 
respondent in this proceeding. 

9. 

I ask the court to schedule a hearing. 

10. 

I ask the court to order the following two essential treatment examiners to 
examine respondent before the hearing date. (Utah Code 62A-15-1202). I have 
tentatively scheduled the appointments as follows.  

Examination one 

Date: _______________ 

Time: ______________  [  ] a.m.  [  ]  p.m. 

Examiner’s name: ______________________________________________ 

Facility name: _________________________________________________ 

Address: ____________________________________________________ 

Examination two 

Date: _______________ 

Time: ______________  [  ] a.m.  [  ]  p.m. 

Examiner’s name: ______________________________________________ 

Form 1001ICF Approved October 17, 
2017 / Revised February 8, 2021 

Petition for Essential Treatment and Intervention 

Page 3 of 4 

 

   

 

 

Facility name: _________________________________________________ 

Address: ____________________________________________________ 

11. 

If the essential treatment examiners determine respondent meets the criteria for 
essential treatment, I ask the court order respondent to undergo essential 
treatment. 

 declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

inancial guarantee 

I _______________________________________________________________ (name) 
agree to pay all treatment costs beyond those covered by the respondent’s health 
insurance policy for all treatment ordered for respondent in this proceeding. 

Signature ► 

Printed Name 

 

 

 

 

Signature ► 

Guarantor’s Printed Name 

Form 1001ICF Approved October 17, 
2017 / Revised February 8, 2021 

Petition for Essential Treatment and Intervention 

Page 4 of 4 

  I

      F

 
Date 

 
Date

Petition for Essential Treatment and Intervention

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from legacy.utcourts.gov (2023-03)
Page(s): 4
Fields(s): 152
Average fields per page: 38
Reading Level: Grade 13
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Petition for Essential Treatment and Intervention

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02