DPP-250Commonwealth of Kentucky

07/2009Cabinet for Health and Family Services

Department of Community Based Services

Division of Protection and Permanency

COMMONWEALTH OF KENTUCKY

______CIRCUIT COURT

CIVIL ACTION NO. ______

IN THE INTEREST OF ______

AN ADULT IN NEED OF PROTECTIVE SERVICES

VERIFIED PETITION FOR THE PROVISION OF

EMERGENCY PROTECTIVE SERVICES

* * * * * * * * * *

Comes the Petitioner, the Commonwealth of Kentucky, Cabinet for Health and Family Services (hereafter the Cabinet), by Counsel, and in its Petition for the provision of Emergency Protective Services, states as follows:

  1. The Cabinet is an agency of the Commonwealth, and is authorized pursuant to KRS Chapter 209 et seq. to provide protective services to adults in need of those services.
  2. ______(hereinafter referred to as“______”) is a female/male approximately ____years old, who resides at ______, ______and is an “adult” within the meaning of KRS 209.020 (4).
  3. The nature of the disability suffered by ______is ______or (undetermined.)
  4. An Ex Parte Order was not issued in this matter.
  5. Several attempts were made to convince ______to accept protective services, the last attempt being made on ______, 2____. At that time, ______appeared unable to fully understand the nature of the services offered and the possible consequences of not accepting those services.
  6. The protective services proposed for ______included the following:
  1. Because ______appears unable to appreciate the serious nature of the situation, and the immediate harm caused by ______’s circumstances at this time, the Cabinet requests that the Court issue an Emergency Protective Services Order to meet the immediate protective needs of ______.
  2. The Cabinet requests that a Guardian Ad Litem be appointed to represent ______best interest.

WHEREFORE, the Petitioner prays that:

  1. The Court sethearing a hearing to be considered as a full and final hearing for the purpose of KRS 209.100.
  2. That, pursuant to this hearing, the Court ratify that protective services, the least restrictive available to serve the protective needs of this individual, are valid and necessary for the continued health and safety of ______.
  3. Any and all other relief to which the Petitioner may be entitled.

Respectfully submitted,

COMMONWEALTH OF KENTUCKY

______

(CountyAttorney or Cabinet Attorney)

By: ______

(Title/address/phone no. of submitting counsel)

VERIFICATION

COMMONWEALTH OF KENTUCKY)

)

COUNTY OF ______)

I, ______, a social worker employed by the Cabinet for Health and Family Services, being duly sworn, state that I have read the foregoing petition and know the contents thereof and that the same is true of my own knowledge, except as to matters therein stated to be alleged on information and belief and as to those matters I believe them to be true.

______

Subscribed and sworn to before me by ______on this the ____ day of ______.

______NOTARY PUBLIC, KENTUCKY

My commission expires: ______

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