4-930. Petition for appointment of a treatment guardian for an adult.
[For use with Rule 1-130 NMRA]
STATE OF NEW MEXICO
COUNTY OF _______________
________________ DISTRICT COURT
In the Matter of _______________________, SI No. _______
PETITION FOR APPOINTMENT
OF A TREATMENT GUARDIAN FOR AN ADULT
Petitioner, ________________________, under Section 43-1-15 NMSA 1978 states:
1. Respondent, ________________________________, is ____ years of age and is a resident of ________________________________ County, New Mexico.
2. Respondent is currently
[ ] a patient at _________________________________ (name of institution or facility).
[ ] in the custody of _________________________________ (name of institution or facility).
[ ] residing in the community at _________________________________ (Respondent’s last-known address).
3. Respondent has a mental disorder as defined by the New Mexico Mental Health Code, Section 43-1-3(O) NMSA 1978, and is currently diagnosed as follows:
4. The symptoms or behaviors that support the diagnosis are as follows:
5. Respondent is receiving treatment at
[ ] _________________________________ (name of institution or facility).
[ ] in community based services.
6. Respondent’s mental health or developmental disabilities professional or physician, ______________________________________ (name and address of professional or physician), is proposing the following course of treatment: ______________________________
7. (OPTIONAL) Respondent was administered emergency medications on ____________________ (date) pursuant to Section 43-1-15(M) NMSA 1978.
8. Petitioner believes that Respondent is incapable of giving or withholding informed consent to the proposed course of treatment, and therefore lacks capacity to make [his] [her] own mental health care treatment decisions.
9. The following efforts have been made by ________________________________ (name of mental health or developmental disabilities professional or physician) to discuss the proposed course of treatment and the associated risks and benefits with Respondent:
10. The following individual or entity has expressed a willingness to serve as a treatment guardian to make substitute decisions for Respondent as to the course of treatment which would be in Respondent’s best interest and consistent with the least drastic means for accomplishing the treatment objective:
Phone Number: ________________________________
11. The proposed treatment guardian is:
(check all that apply)
[ ] A family member or friend of Respondent.
[ ] A “contract treatment guardian” with the Office of Guardianship.
[ ] A court appointed guardian under the Probate Code.
[ ] An agent designated or nominated by Respondent when Respondent had capacity.
[ ] A surrogate under the Uniform Health Care Decisions Act.
12. Petitioner has provided the proposed treatment guardian with a copy of Form 4-931 NMRA which sets forth the duties and responsibilities of a treatment guardian.
13. (OPTIONAL) Petitioner believes that Respondent has the following designated or court-appointed agent(s): _________________________________________________________
(name and type of all designated or court-appointed agents).
14. Petitioner intends to call the following witnesses: ________________________________
WHEREFORE, Petitioner prays that the Court find that Respondent is not capable of making [his] [her] own mental health treatment decisions, and that it appoint the above-named person to serve as a treatment guardian for Respondent and to serve in such capacity for
[ ] _____ days;
[ ] _____ months;
[ ] Respondent’s course of hospitalization
[ ] Respondent’s duration of detention or incarceration; or
[ ] other: __________________________________________;
provided that such appointment shall not exceed one year without further court review and shall be for a time period consistent with the treatment needs of Respondent. Petitioner further prays for such other relief as the Court may deem proper.
(Signature of attorney or of self-represented Petitioner)
(To be used only by self-represented petitioners)
I, ____________________________, affirm under penalty of perjury under the laws of the State of New Mexico that the information above is true and correct.
(Signature and date)
[Adopted by Supreme Court Order No. 14-8300-013, effective for all cases filed or pending on or after December 31, 2014.]