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In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

In the matter of essential treatment for 

Order on Petition for Essential 
Treatment and Intervention 
(Utah Code 62A-15-1205) 

_____________________________________ 
Respondent 

_______________________________ 
Case Number 

_______________________________ 
Judge  

The matter before the court is a Petition for Essential Treatment and Intervention. This 
matter is being resolved by a hearing held on __________________________ (date), 
notice of which was served on all parties. 

[  ] was represented by _________________________________________ (name). 

Petitioner (Choose all that apply.) 

[  ] was present   

[  ] was not present. 

[  ] was not represented. 

Respondent (Choose all that apply.) 

[  ] was present   

[  ] was not present. 

[  ] was not represented. 

 

1004ICF Approved October 17, 2017 / 
Revised May 1, 2019 
 

[  ] was represented by _________________________________________ (name). 

Order on Petition for Essential Treatment and 
Intervention 

Page 1 of 4 

 

  N

  A

  C

  P

  E

ame 

ddress 

hone 

mail 

ity, State, Zip 

 

1. 

2. 

3. 

4. 

5. 

6. 

 

The court finds: 

The essential treatment examiners’ findings show: 

There  [  ] is    [  ] is not  clear and convincing evidence that respondent suffers 
from a substance use disorder as defined in the current edition of the Diagnostic 
and Statistical Manual of Mental Disorders published by the American Psychiatric 
Association. 

There  [  ] is    [  ] is not  clear and convincing evidence that respondent can 
reasonably benefit from the essential treatment. 

There  [  ] is    [  ] is not  clear and convincing evidence that respondent is unlikely 
to substantially benefit from a less-restrictive alternative treatment 

There  [  ] is    [  ] is not  clear and convincing evidence that Respondent presents 
a serious harm to self or others. 

Having considered the documents filed with the court, the evidence and the arguments, 
and now being fully informed, 

The court orders: 

The Petition is   [  ] granted    [  ] denied. 

[  ]  Respondent is ordered to receive essential treatment at the following local 
substance abuse authority or approved treatment facility or program: 

 

7. 

[  ]  The initial period of respondent’s treatment shall be up to _________ days, 

but not more than 360 days, and shall be reviewed by the essential treatment 
provider at least every 90 days. 

8. 

[  ]  Petitioner shall be respondent’s personal representative for purposes of 

respondent's essential treatment. (45 C.F.R. Sec. 164.502(g).) 

9.  

[  ]  ________________________________________________________ (name) 
is ordered to pay all of treatment costs beyond those paid by respondent’s 
health insurance policy for all court-ordered treatment for respondent. 

10. 

[  ]  Other: 

 

1004ICF Approved October 17, 2017 / 
Revised May 1, 2019 
 

Order on Petition for Essential Treatment and 
Intervention 

Page 2 of 4 

 

 
Date 

Judge’s signature may instead appear at the top of the first page of this document. 

 

Signature ► 

Judge 

 

 

1004ICF Approved October 17, 2017 / 
Revised May 1, 2019 
 

Order on Petition for Essential Treatment and 
Intervention 

Page 3 of 4 

 

 

 

 

 

 
Date 

 

Certificate of Service 

I certify that I filed with the court and am serving a copy of this Order on Petition for Essential Treatment 
and Intervention on the following people. 

Person’s Name 

Service Method 

Service Address 

Service 
Date 

 

 

 

 

 

 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

Signature ► 

Printed Name 

 

 

1004ICF Approved October 17, 2017 / 
Revised May 1, 2019 
 

Order on Petition for Essential Treatment and 
Intervention 

Page 4 of 4

Order on Petition for Essential Treatment and Intervention (Utah Code 62A-15-1205)

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): 117
Average fields per page: 29
Reading Level: Grade 12
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.

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

Order on Petition for Essential Treatment and Intervention (Utah Code 62A-15-1205)

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Identified Data Fields:

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