Form 46-21

The petition must be filed in the district court in the county in which the petitioner resides. Tex. Fam. Code § 35A.002. The petition must be styled “ex parte,” be in the name of the child, and be verified by the petitioner. Tex. Fam. Code § 35A.003(1), (2).

NOTICE: THIS DOCUMENT
CONTAINS SENSITIVE DATA

[Caption. The suit must be styled “ex parte” and be in the name of the child.]

Petition for Temporary Authorization to Consent to Voluntary Inpatient Mental Health Services for Child

[Name[s] of petitioner[s]], Petitioner[s], request[s] the Court to issue an order granting Petitioner[s] temporary authorization to consent to voluntary inpatient mental health services for the child, [name of child]. In support, Petitioner[s] show[s]:

1.Discovery in this case is intended to be conducted under [level 2/level 3] of rule 190 of the Texas Rules of Civil Procedure. [If level 3, see form 5-1.]

Preservation of Evidence: Respondent is put on notice to preserve and not destroy, con­ceal, or alter any evidence or potential evidence relevant to the issues in this case, including tangible documents or items in Respondent’s possession or subject to Respondent’s control and electronic documents, files, or other data generated by or stored on Respondent’s home computer, work computer, storage media, portable systems, electronic devices, online reposi­tories, or cell phone.

2.Petitioner[s] object[s] to the assignment of this matter to an associate judge for a trial on the merits or presiding at a jury trial.

3.This Petition for Temporary Authorization to Consent to Voluntary Inpatient Men­tal Health Services for Child is brought by [name[s]], Petitioner[s]. [The last three numbers of [Petitioner/[name]]’s driver’s license number are [numbers]./[Petitioner/[name]] has not been issued a driver’s license.] [The last three numbers of [Petitioner/[name]]’s Social Security number are [numbers]./[Petitioner/[name]] has not been issued a Social Security number.] [Petitioner/[name]]’s date of birth is [date of birth]. [Petitioner/[name]]’s current physical address is [address]. [If applicable, repeat statements for other petitioner.]

Respondent is [name of respondent]. [Respondent should be served with process [include if applicable: at [address, city, state, zip code]]/No service on Respondent is neces­sary at this time].

4.[No court has continuing jurisdiction of this suit or of the child the subject of this suit./A court order designating [conservatorship/guardianship] over the child the subject of this suit was entered on [date] in the [designation] Court of [county], [state], and a copy is attached as Exhibit [exhibit number/letter].]

5.The following child is the subject of this suit:

Name:

Sex:

Birth date:

Current physical address:

6.The following parties may be affected by this suit:

Name:

Current physical address:

Current mailing address:

Relationship: [e.g., managing conservator, possessory conservator, parent, guardian of person, guardian of estate]

[Process should be served [include if applicable: at [address, city, state, zip code]]./No service is necessary at this time./Citation by publication or other substituted service is neces­sary for the reasons stated in the affidavit attached as Exhibit [exhibit number/letter].]

Information required by section 152.209 of the Texas Family Code is provided in the affidavit attached as Exhibit [exhibit number/letter].

7.Petitioner[s] [is/are] the child’s [grandparent[s]/adult [brother/sister]/adult [aunt/uncle]] and [is/are] eligible to consent to treatment under section 32.001[(a)(1)/(a)(2)/(a)(3)] of the Texas Family Code.

8.[There are no court proceedings with respect to the child in this state or another state known to Petitioner[s]./There is a [criminal/civil] court proceeding with respect to the child pending in the [designation] Court of [county], [state].] [Describe status as applicable. If there is a proceeding with any order that designates conservatorship or guardian of the child, attach the order as an exhibit.]

9.Petitioner[s] [has/have] had actual care, custody, and control of the child for the preceding six months. During that six-month period, the child has resided with Petitioner[s] on the following dates: [dates].

10.Petitioner[s] [is/are] unable to obtain signed, written documentation from a parent, conservator, or guardian of the child because [state reasons].

11.A certificate of medical examination for mental illness prepared by a physician who examined the child on [date not earlier than third day before petition is filed] is attached to this petition as Exhibit [exhibit number/letter], accompanied by a sworn statement, as Exhibit [exhibit number/letter], containing the physician’s opinion, and the detailed reasons for that opinion, that the child is a person with mental illness or who demonstrates symptoms of a seri­ous emotional disorder and who presents a risk of serious harm to self or others if not immedi­ately restrained or hospitalized.

12. Petitioner[s] pray[s] that the Court grant this Petition for Temporary Authoriza­tion to Consent to Voluntary Inpatient Mental Health Services for Child as requested above. [Include if applicable: Petitioner[s] pray[s] that citation and notice issue as required by law.] Petitioner[s] pray[s] for general relief.

   
[Name]
Attorney for Petitioner[s]
State Bar No.:
[Email address]
[Address]
[Telephone]
[Fax]

Verification

The undersigned states under oath: “I am Petitioner in the foregoing Petition for Tem­porary Authorization to Consent to Voluntary Inpatient Mental Health Services for Child. I have personal knowledge of the allegations and facts stated herein, and they are true and cor­rect.”

   
[Name of petitioner]

Signed under oath before me on________________________.

   
Notary Public, State of Texas