__________

__________

Defendant

__________

(1) The undersigned is authorized by the State Commissioner of Mental Health to submit this application for a first retention order for and on behalf of the said Commissioner.

(2) This application for a first retention order is being submitted to the following court: [check one and print name and address of indicated court]

(3) This application for a first retention order is made pursuant to subdivision 8 of CPL 330.20. If this application is granted, the undersigned requests that the first retention order issued by this court take effect at the expiration of the period referred to in paragraph (8) of this application and that it authorize continued custody of the above-named defendant by the Commissioner of Mental Health for a period not to exceed one year.

(4) The above-named defendant is currently in the custody of the State Commissioner of Mental Health and is confined in a secure facility for care and treatment pursuant to

□ a commitment order issued under the provisions of subdivision 6 of CPL 330.20

□ a recommitment order issued under the provisions of subdivision 14 of CPL 330.20

by the following court on the following date:

(5) Prior to the issuance of the recommitment order referred to in paragraph (4) of this application, a transfer order and a release order were issued by the following courts on the following dates:

(6) The court referred to in paragraph (4) of this application found the above-named defendant to have a dangerous mental disorder, as that term is defined in paragraph (c) of subdivision 1 of CPL 330.20.

(8) The order referred to in paragraph (4) of this application directed that the above-named defendant be confined in a secure facility for care and treatment for six months from the date of the said order. The period prescribed in the said order expires on: __

(9) This application is made upon the ground that the undersigned is of the view that the above-named defendant: [check one]

□ currently suffers from a dangerous mental disorder as that term is defined in paragraph (c) of subdivision 1 of CPL 330.20 in that the defendant currently suffers from an affliction with a mental disease or mental condition which is manifested by a disorder or disturbance in behavior, feeling, thinking, or judgment to such an extent that the defendant requires care, treatment and rehabilitation, and that because of such condition the defendant currently constitutes a physical danger to himself or others.

□ does not currently suffer from a dangerous mental disorder, as that term is defined in paragraph (c) of subdivision 1 of CPL 330.20, but the above-named defendant is mentally ill in that the defendant currently suffers from a mental illness for which care and treatment as a patient, in the inpatient services of a psychiatric center under the jurisdiction of the State Office of Mental Health, is essential to such defendant's welfare and that his judgment is so impaired that he is unable to understand the need for such care and treatment.

(10) The annexed psychiatric reports are made a part of this application for a first retention order and support the opinion of the undersigned concerning the current mental condition of the above-named defendant.

(11) Pursuant to the provisions of subdivision 8 of CPL 330.20, this application is being made at least 30 days prior to the expiration of the period referred to in paragraph (8) of this application.

(12) Written notice of this application for a first retention order has been given to the above-named defendant, counsel for the defendant, the Mental Health Information Service and the District Attorney. This written notice was given at least 15 days prior to the date that this application will be submitted to the court indicated in paragraph (2) of this application.

(13) No previous application for a first retention order has been made to any court.

WHEREFORE, the undersigned respectfully requests that this application be granted and that a first retention order issue authorizing continued custody of the above-named defendant by the Commissioner of Mental Health for a period not to exceed one year from the date such retention order takes effect.

Signature

Type or Print Name

Title

Date: _________

Upon receipt of the above application for a first retention order, the court may, on its own motion, conduct a hearing to determine whether the defendant has a dangerous mental disorder.

The court must conduct a hearing to determine whether the defendant has a dangerous mental disorder if a timely demand is made to the court by the defendant, counsel for the defendant, the Mental Health Information Service or the District Attorney.

A demand for a hearing is timely if it is made within 10 days from the date that this notice of application was given to you.

You may make a demand for a hearing by writing directly to the court indicated in paragraph (2) of the above application.

Failure to demand a hearing will permit the court to rule on the above application without a hearing.

You are hereby advised that the Mental Health Information Service, which is an agency of the Supreme Court of the State of New York, has been established to provide you with assistance and information as to your rights under the law and the procedures governing your retention. You are entitled to communicate with a representative of the Service at any time.

The location and telephone number of the Mental Health Information Service office serving your hospital appear below.

You may communicate with the Mental Health Information Service office directly, or you may request a member of the hospital staff to inform the Service of your desire to see a representative. A member of the Service will then see you in the hospital.

You have a right to a court hearing on the above application if you make a timely demand for such hearing. You have a right to be represented by counsel at such hearing and you have the right to have counsel assigned by the court if you are financially unable to obtain your own lawyer.

Mental Health Information Service