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.]

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.:
[E-mail 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