IN THE____ _____ JUDICIAL DISTRICT COURT ______ ______ COUNTY, STATE OF UTAH _____________________________________________ In the Matter of:

ORDER APPOINTING DESIGNATED EXAMINER AND REPORT OF EXAMINATION CASE NO:

____________________________________________________________ TO:______________________________ An application for the involuntary commitment of ______ was filed on ______________________.

Proposed Patient

______,

Now, therefore, pursuant to the provisions of Utah Code Annotated 62A-15-631 (2003), you are hereby appointed as designated examiner to examine the above-named proposed patient at:_________________ and to report to the court orally or in writing your expert opinion which will assist the court in making a determination as to whether or not the proposed patient meets the criteria for involuntary commitment. Pursuant to the provisions of UCA 62A-15-631(8)(b), you shall inform the patient, if not represented by an attorney that, if desired, the patient does not have to say anything, the nature and reasons for the examination, that it was ordered by the court, that any information volunteered could form part of the basis for his or her involuntary commitment, and that findings resulting from examination will be made available to the court. It is further ordered that such examination be completed on or before the _ _ day of __________, 20_____, and that you hereafter complete and file the report attached herewith setting forth the required opinion and facts as directed above.

Dated this ______ day of ______________, 20______. _______________________

District Court Judge

DSAMH Form 36-6, Revised 2012

Utah Code Annotated 62A-15-631(8)(a) (2003)