In the Superior Court of the State of California
for the County of _____

The People of the State of California
Concerning

and

_____ Respondents _____

No. _____
Petition for 
Evaluation 

________, residing at _____ (tel. ____), being duly sworn, alleges: That there is now in the county, in the City or Town of _____, a person named _____, who resides at _____, and who is, as a result of mental disorder:

(1) A danger to others.
(2) A danger to himself or herself.
(3) Gravely disabled as defined in subdivision (h) of § 5008 of the Welfare and Institutions Code (Strike out all inapplicable classifications).

That the person is ____ years of age; that __? the person is ____­(sex); and that __? the person is _____ (single, married, widowed, or divorced); and that _____ occupation is _____.

That the facts upon which the allegations of the petition are based are as follows: That __? the person, at _____ in the county, on the _____ day of _____, 20__,

That petitioner’s interest in the case is 

That the person responsible for the care, support, and maintenance of the person, and their relationship to the person are, so far as known to the petitioner, as follows: (Give names, addresses, and relationship of persons named as respondents)

Wherefore, petitioner prays that evaluation be made to determine the condition of ____, alleged, as a result of mental disorder, to be a danger to others, or to himself or herself, or to be gravely disabled.

_____ _____ Petitioner _____

Subscribed and sworn to before me this ____ day of _____ 20__.

_____ , Clerk of the Court

_____ By  Deputy