To the Superior Court of the State of California
for the County of ______

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The authorized agency providing 14-day intensive treatment, County of _________, has custody of: _________

Name ____________

Address ____________

Age ____________

Sex ____________

Marital status ____________

Religious affiliation ____________

The undersigned allege that the above-named person presents an imminent threat of taking his own life.
This allegation is based upon the following facts:

This allegation is supported by the accompanying affidavits signed by ____________.

The above-named person has been informed of this allegation and has been advised of, but has not been able or willing to accept referral to, the following services:

We, therefore, certify the above-named person to receive additional intensive treatment for no more than 14 days beginning this day of (Month), 19__, in the intensive treatment facility herein named ________.

We hereby state that a copy of this notice has been delivered this day to the above-named person and that he has been clearly advised of his continuing legal right to a judicial review by habeas corpus, and this term has been explained to him.

(Date)

Signed 

Countersigned _____ Representing intensive treatment facility _____