1. A. An application for court-ordered evaluation shall, according to A.R.S. § 36-521, be made on AHCCCS form MH-100, Titled “Application for Involuntary Evaluation,” set forth in Exhibit A.

2. B. Any mental health agency or service provider that receives an application for court-ordered evaluation shall immediately refer the applicant for pre-petition screening and petitioning for court-ordered evaluation, provided for in A.R.S. Title 36, Chapter 5, Article 4, to:

   1. 1. A health plan; or
   2. 2. If a county has not contracted with a health plan for pre-petition screening and petitioning for court-ordered evaluation, the county.

3. 10. Applicant information:

   Name of Applicant:

   Address of Applicant:

   Relationship to or Interest in the Proposed Patient:

4. 11. In the opinion of the Petitioner, the person is _____ is not ____ in such a condition that, without immediate or continuing hospitalization, s/he is likely to suffer serious physical harm or inflict serious physical harm upon another person.

5. 12. In the opinion of the Petitioner, evaluation should ____ should not ____ take place on an outpatient basis, based upon the following reasons:

   PETITIONER REQUESTS THAT THE COURT:

   Issue an Order requiring the person to be given an ____ Inpatient ____ Outpatient evaluation.

   DATE Signature Of Petitioner

   Printed or Typed Name

   SUBSCRIBED AND SWORN to before me this _______ day of _________________________________, 19 _____.

   Notary Public

   My Commission Expires:

   ADHS/BHS Form MH-105 (9/93)

Exhibit A. Application for Involuntary Evaluation

APPLICATION FOR INVOLUNTARY EVALUATION

(Pursuant to A.R.S. § 36-520)

NAME, ADDRESS AND TELEPHONE NUMBER OF:

1) Guardian

2) Spouse

3) Next of Kin

4) Significant Other Persons

DATE SIGNATURE OF APPLICANT

Printed or Typed Name of Applicant

Relationship to Proposed Patient

Applicant’s Address

Applicant’s Telephone

SUBSCRIBED AND SWORN to before me this __________ day of ____________________, 19 ________

Notary Public

My Commission Expires:

________________________

ADHS/BHS Form MH-100 (9/93)

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Exhibit A repealed, new Exhibit A adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3). Renumbered from a position after R9-21-502 by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2).

Exhibit B. Petition for Court-ordered Evaluation

PETITION FOR COURT-ORDERED EVALUATION

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Exhibit B repealed, new Exhibit B adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3). Renumbered from a position after R9-21-502 by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2).

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Section repealed; new Section R9-21-501 renumbered from R9-21-502 and amended by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2). Amended by final rulemaking at 29 A.A.R. 898 (April 21, 2023), effective May 30, 2023 (Supp. 23-1).