If any minor is alleged to be an individual with a serious emotional disturbance and in such condition that immediate intervention is necessary for the protection from physical harm to himself or others, any person, eighteen years of age or older, may petition the chairman of the county board of mental illness where such minor is found, stating the factual basis for concluding that such minor is an individual with a serious emotional disturbance and in immediate need of intervention. The petition shall be upon a form and be verified by affidavit. The petition shall include the following:

1. (1) A statement by the petitioner, on the basis of personal knowledge, that such minor is, as a result of a serious emotional disturbance, a danger to self or others;
2. (2) The specific nature of the danger;
3. (3) A summary of the information upon which the statement of danger is based;
4. (4) A statement of facts which caused the minor to come to the petitioner's attention;
5. (5) The name, address, and signature of the petitioner and a statement of the petitioner's interest in the case; and
6. (6) The name of the minor to be evaluated and the address and age of the minor and the name and address of the minor's parents, guardian, or nearest relative.

Source: SL 1991, ch 220 , § 320; SL 1993, ch 213 , § 127; SL 1994, ch 255 , § 5.