Sonoma — CARE-100 form

Source: https://www.courts.ca.gov/documents/care100.pdf

CONFIDENTIAL CARE-100 ATTORNEY OR PETITIONER WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: EMAIL ADDRESS: ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CARE ACT PROCEEDINGS FOR (name):

RESPONDENT CASE NUMBER:

PETITION TO BEGIN CARE ACT PROCEEDINGS

For information on completing this form, see Information for Petitioners—About the CARE Act (form CARE-050-INFO), visit the CARE Act webpage on the self-help website at https://selfhelp.courts.ca.gov/care-act, or contact your local court's self-help center. To find the location and hours of the self-help center, click https://selfhelp.courts.ca.gov/self-help/find-self-help .

1. I (enter your name here): am asking the court to find that (name of the person you want services for, who is called the respondent):

   is eligible to participate in the CARE Act process. The respondent was born on (date of birth, if you know it): or I do not know the respondent's date of birth, but the respondent is (approximate age, in years): years old.

2. I am 18 years of age or older and (check all categories that apply to you): a. A person who lives with the respondent. i. A first responder—including a peace officer, b. A spouse or registered domestic partner, parent, firefighter, paramedic, emergency medical sibling, child, or grandparent of the respondent. technician, mobile crisis response worker, or

c. A person authorized to act in place of the homeless outreach worker—who has had repeated
respondent's parent. interactions with the respondent.
j. The public guardian or public conservator of this d. The director of the county behavioral health agency
county.* of this county.*
e. A licensed behavioral health professional who is or k. A conservator or proposed conservator referred
has been, within the past 30 days, treating or from a proceeding under Welfare and Institutions
supervising the treatment of the respondent.* Code section 5350.
f. The director of a hospital in which the respondent is l. The director of adult protective services of this
hospitalized.* county.*
g. The director of a public or charitable organization, m. The director of a California Indian health services
agency, or home program or tribal behavioral health department that
has, within the past 30 days, provided or is (1) who is or has been, within the past 30 days,
currently providing behavioral health services to the providing behavioral health services to the
respondent.* respondent;* or
(2) in whose institution the respondent resides.* n. A California tribal court judge before whom the
respondent has appeared within the past 30 days.* h. The respondent.
* If you are in a category above that is followed by *, you may designate someone to file the petition on your behalf. If you have
been designated to file a petition by a person in a category followed by *, check that category and enter your name above.

3. I have interacted with the respondent as follows (describe when (give the date) you last saw them, and what happened when you interacted with the respondent): If you need more space for your answer, please use a separate piece of paper and label it as Attachment 3.

Judicial Council of California, courts.ca.gov CARE-100, Page 1 of 5 Rev. July 1, 2026, Alternative Mandatory Form Welf. & Inst. Code, §§ 5972–5975, 5977, 5978 Petition to Begin CARE Act Proceedings

CONFIDENTIAL CARE-100 CARE ACT PROCEEDINGS FOR (name): CASE NUMBER:

RESPONDENT

4. a. The respondent lives or was last found at (give the respondent's address if they have one and you know it, including a post office box where they get mail; otherwise, describe where the respondent lives, the last location where they were staying, or locations where they are frequently found):

   b. The respondent's other contact information is: (telephone number, if any): The respondent does does not respond to text messages. (email address, if any): c. I believe that the best ways to contact the respondent are (check all that apply): (1) by visiting them in person (2) by calling them on the phone (3) by sending them text messages (4) by sending them email (5) by sending them mail (6) other (describe): d. The respondent needs assistance reading hearing or understanding speaking English. The respondent's preferred language is (specify one or more languages):

5. The respondent (check a or b; if you check b, you must also check either (1) or (2)): a. Is a resident of the county in which this petition is filed. b. Is not a resident of the county in which this petition is filed. The respondent's county of residence is (if you know it): (1) The respondent is located in the county in which this petition is filed. (2) The respondent is a defendant or respondent in a criminal or civil proceeding pending in the superior court of the county in which this is filed.

6. Evidence supporting this petition includes (you must check and provide at least one of the following): a. The declaration of a licensed behavioral health professional (form CARE-101), attached and labeled as Attachment 6a. b. A statement or documents showing that the respondent has been hospitalized two or more times for involuntary treatment and that the most recent involuntary hospital stay ended less than 60 days ago. Note: As used in this form, "involuntary treatment" refers only to a 14-day hold authorized by Welfare and Institutions Code section 5250. It does not refer to treatment authorized by any other statutes, including but not limited to Welfare and Institutions Code sections 5150, 5260, 5270.15, and 5270.70. (If you checked 6b above, please check (1) and provide the information below, or check (2) and attach the documents, or do both.) (1) I know personally that the respondent was hospitalized for involuntary treatment. (Describe what happened each time, and explain how you know about it): (2) I have attached documents showing that the respondent was hospitalized two or more times for involuntary treatment and labeled the documents Attachment 6b1, 6b2, 6b3, etc. (Include, for example, your own signed declaration (only if you have personal knowledge of the respondent's involuntary treatment), copies of certifications for intensive treatment, signed declarations by persons who witnessed the respondent's involuntary treatment, or other records.)

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CONFIDENTIAL CARE-100 CARE ACT PROCEEDINGS FOR (name): CASE NUMBER:

RESPONDENT

7. To the best of my knowledge, the respondent meets each of the requirements below: Check here if all the information requested in items 7a through 7f is included in form CARE-101. If it is, you can skip the rest of this question, if you choose. Otherwise, explain below. Note: Some details you enter in items 7a through 7f may overlap. If you notice you're repeating yourself, you can say that you already gave the information and mention where you said it before. a. The respondent has a diagnosis as defined in the current Diagnostic and Statistical Manual of Mental Disorders of schizophrenia spectrum disorder or another psychotic disorder in the same class, or bipolar I disorder with psychotic features, except psychosis related to current intoxication. (Explain below):

   b. The respondent is currently experiencing a serious mental disorder, as defined in Welfare and Institutions Code section 5600.3(b)(2), because the disorder: (1) Is severe in degree and persistent in duration; (2) May cause, or has caused, behavior that interferes substantially with the respondent's primary activities of daily living; and (3) May result, or has resulted, in the respondent's inability to maintain stable adjustment and independent functioning without treatment, support, and rehabilitation for a long or indefinite period. (Describe the seriousness, length, and effects of the respondent's mental disorder below):

   c. The respondent is not clinically stabilized in ongoing voluntary treatment. A respondent is clinically stabilized in ongoing treatment if both of the following are true: (1) The respondent's condition is stable and not deteriorating; and (2) The respondent is currently engaged in treatment and managing symptoms through medication or other therapeutic interventions. (Describe the respondent's current condition and any ongoing treatment below):

   d. At least one of the following is true (complete (1) or (2) or both): (1) The respondent is unlikely to survive safely in the community without supervision and the respondent's condition is substantially deteriorating. (Explain why the respondent is unlikely to survive safely in the community, describe the type of supervision the respondent would need to survive safely, and describe how the respondent's physical or mental condition has recently grown worse):

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CONFIDENTIAL CARE-100 CARE ACT PROCEEDINGS FOR (name): CASE NUMBER:

RESPONDENT

7. d. (2) The respondent needs services and supports to prevent a relapse or deterioration that would be likely to lead to grave disability or serious harm to the respondent or others. (Describe the services and supports needed by the respondent, and explain why the respondent would become gravely disabled or present a risk of harm to self or others without them):

   e. Participation in a CARE plan or CARE agreement would be the least restrictive alternative necessary to ensure the respondent's recovery and stability. (Explain why no other less restrictive treatment plan would work as well for the respondent):

   f. The respondent is likely to benefit from participation in a CARE plan or CARE agreement because (explain below):

8. OPTIONAL: Other information (if applicable, check any of the following statements that are true, and give the requested information if you know it): a. The respondent needs interpreter services or an accommodation for a disability. (If you know, describe what they need):

   b. The respondent is served by a regional center. (If you know, give the center's name and the services it provides to them):

   c. The respondent is or was a member of the state or federal armed services or reserves. (If you know, give branch name):

   d. The respondent is an enrolled member of a federally recognized Indian tribe. (If you know, give the tribe's name and mailing address):

   e. The respondent is receiving services from a California Indian health services program, a California tribal behavioral health department, or a California tribal court. (If you know, give the name and mailing address of the program, department, or court):

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CONFIDENTIAL CARE-100 CARE ACT PROCEEDINGS FOR (name): CASE NUMBER:

RESPONDENT

8. f. The respondent is within a juvenile court's dependency, delinquency, or transition jurisdiction. (If you know, provide the following): (1) Court: (2) Case number: (3) The respondent's attorney in the juvenile court proceeding (name): (mailing address): (telephone number): (email address):

g. The respondent has a court-appointed conservator. (If you know, provide the following):
(1) Court:
(2) Case number:
(3) The respondent's attorney in the conservatorship proceeding (name):
(mailing address):
(telephone number): (email address):

9. Court referral (complete this item only if it applies; if you don't know some of the requested information, leave that part blank): This petition is filed in response to a referral of the respondent from another court proceeding. a. Court, department, and judicial officer:

   b. Case number: c. Type of proceeding from which the respondent was referred (check one): (1) Mental competence proceeding arising from a criminal prosecution (Pen. Code, §§ 1370, 1370.01) (2) Assisted outpatient treatment (Welf. & Inst. Code, §§ 5346–5348) (3) Lanterman-Petris-Short Act conservatorship (Welf. & Inst. Code, §§ 5350–5372) d. The referral order is attached and labeled as Attachment 9 (optional). e. The respondent's attorney in the referring proceeding (name): (mailing address): (telephone number): (email address):

10. Number of pages attached:

Date:

Type or Print Name of Attorney, if Any Signature of Attorney, if Any

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

Type or Print Name of Petitioner Signature of Petitioner

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