Family Court / Admissions Office / Vermont State Hospital / Medicare / / /
Position
certifying physician / physician / Name Physician / representative of an authorized screening agency / town health officer / law enforcement officer / a licensed physician / social worker / nurse / Address Physician / town service officer / or / Telephone Number PHYSICIAN / town service officer / physician / psychologist / head / licensed physician / superintendent / same physician / Commissioner / psychologist / social worker / applicant and certifying physician / /
FORM NO. MH-9A Revised[removed]TO COMMENCE PROCEEDINGS FOR THE INVOLUNTARY TREATMENT OF AN INDIVIDUAL NON EMERGENCY