UNITED STATES BANKRUPTCY COURT
EASTERN DISTRICT OF NORTH CAROLINA
RALEIGH DIVISION

IN RE:									
JOHN Q. PUBLIC	

	DEBTOR

CASE NO.

12-34567-8-ATS	

APPLICATION FOR APPROVAL OF MENTAL HEALTH EVALUATION

Comes now the debtor, and requests the Court to approve a pro bono or low cost mental health evaluation, and states as follows:

1.	ab	The debtor’s mental health is a genuine issue of material fact to these bankruptcy proceedings in that . . . .        (state relevance, examples: the debtor claims that debtor’s mental health is relevant to the debtor’s failure to attend meeting of creditors or hearings;  the debtor claims that debtor’s mental health is relevant to allegations related to challenges to the debtor’s general discharge (Section 727) or arguments for an exception to discharge based upon fraud allegations (Section 523(a)(2)); the debtor seeks to discharge student loans based upon mental illness under Section 523(a)(8) or 42 U.S.C. 294g; the debtor seeks to avoid a default judgment based upon excusable neglect; or the debtor seeks to exempt personal injury award related to mental health); 
    
2.	ab	Based upon information and belief, the debtor’s mental health should be examined by a mental health professional to determine whether the debtor may have . . . (examples: manic depression, bipolar disorder, schizophrenia, paranoid personality disorder), or another recognized mental illness;

3.	ab	Based upon the bankruptcy schedules and the debtor’s available income and assets as follows, (set out monthly income and any liquid assets), the debtor is currently unable to pay for a mental health evaluation that is necessary and relevant to bankruptcy issues presented;
	
4.	ab	After making diligent efforts to obtain mental health services to assist the debtor, the debtor has been unable to obtain relevant services based upon available health insurance, public health programs, or other third party services. 
	
5.	ab	A copy of this application has been transmitted to the Bankruptcy Administrator and  (identify any other interested party).

	Wherefore, based upon the foregoing, the debtor respectfully requests that the Court approve a pro bono or low cost mental health evaluation in this case.

UNITED STATES BANKRUPTCY COURT
EASTERN DISTRICT OF NORTH CAROLINA
RALEIGH DIVISION

IN RE:									
JOHN Q. PUBLIC	

	DEBTOR

CASE NO.

12-34567-8-ATS	

						ORDER

	Based upon the Application for Approval of Mental Health Evaluation by the debtor and the representations contained therein, the Court approves the debtor’s request for a pro bono or low cost mental health evaluation for purposes of this action.  
	SO ORDERED.

	DATED:  

							_________________________
							Bankruptcy Judge