IN THE CIRCUIT COURT, _________________ JUDICIAL CIRCUIT,
IN AND FOR ____________________ COUNTY, FLORIDA
IN RE: ___________________________ Case No.: __________________________
ORDER REQUIRING EVALUATION FOR
INVOLUNTARY OUTPATIENT PLACEMENT
THIS MATTER came to be heard on ___________________________, pursuant to s. 394.467, F.S.,
on petition for involuntary inpatient placement of the above-named person and the court being advised in the
premises, finds as follows:
1. The above-named person does not meet the criteria for involuntary inpatient placement in a mental health treatment or
receiving facility.
2. The above-named person is 18 years of age or older, has a mental illness, and has a history of lack of compliance with
treatment for mental illness.
3. The above-named person is unlikely to survive safely in the community without supervision; this finding is supported
by testimony of __________________________________________________________________________ as to
his/her clinical determination.
4. The above-named person has:
A. At least twice within the preceding 36 months been involuntarily admitted to a receiving or treatment
facility as defined in s.394.455, or received mental health services in a forensic or correctional facility, or
B. Engaged in or attempted to engage in one or more acts of serious violent behavior toward self or others
within the preceding 36 months.
5. The above-named person is, as a result of mental illness, unlikely to voluntarily participate in recommended treatment
and has either refused voluntary placement for recommended treatment after sufficient and conscientious explanation
and disclosure of the purpose of placement, or is unable to determine whether placement is necessary.
6. In view of the person’s treatment history and current behavior, the person is in need of involuntary outpatient
placement in order to prevent a relapse or deterioration that would be likely to result in serious bodily harm to the
person or others, or a substantial harm to the person’s well-being through neglect or refusal to care for self as set forth
in s. 394.463(1);
7. It is likely that the person will benefit from involuntary outpatient placement. All available less restrictive alternatives
that would offer an opportunity for improvement of his or her condition are either inappropriate or unavailable.
Whereupon, IT IS ORDERED
1. That the above-named person be discharged this date from any involuntary inpatient placement and
treatment for mental illness.
2. That the above-named person shall be evaluated by __________________________________located
at ___________________________________________for involuntary outpatient placement within
_______days of the date of this hearing.
DONE AND ORDERED in Chambers at _____________ County, Florida, this __ day of _________, 20____.
________________________________ ____________________________________________________________
Printed Name of Circuit Court Judge Signature of Circuit Court Judge
See s. 394.4655(6)(c), Florida Statues
CF-MH 3115, Feb 05 (Recommended Form) BAKER ACT