California Code, Welfare and Institutions Code - WIC § 5205

In the Superior Court of the State of California

for the County of __________

______________________________________________________________

The People of the State of California

No. __________

Concerning

Petition for

Evaluation

______________________________________________________________

______________________________________________________________

__________, residing at __________ (tel. __________), being duly sworn, alleges: That there is now in the county, in the City or Town of _______________, a person named __________, who resides at ____________, and who is, as a result of mental disorder:

(1) A danger to others.

(2) A danger to himself or herself.

(3) Gravely disabled as defined in subdivision (h) of Section 5008 of the Welfare and Institutions Code (Strike out all inapplicable classifications).

That the person is ____ years of age; that __ the person is _____ (sex); and that __ the person is _____ (single, married, widowed, or divorced); and that ________ occupation is _______________.

That the facts upon which the allegations of the petition are based are as follows: That __ the person, at __________ in the county, on the ______ day of __________, 20__,

That petitioner's interest in the case is _______________________________________________________

___________________________________________________________________________________________________

That the person responsible for the care, support, and maintenance of the person, and their relationship to the person are, so far as known to the petitioner, as follows: (Give names, addresses, and relationship of persons named as respondents)

Wherefore, petitioner prays that evaluation be made to determine the condition of __________, alleged, as a result of mental disorder, to be a danger to others, or to himself or herself, or to be gravely disabled.

_________________________________________________

Subscribed and sworn to before me this ____ day of __________ 20__.

_________________, Clerk of the Court

By ______________________________ Deputy