Any interested person may file a Uniform Alcohol and Drug Commitment Affidavit with the chancery court for a judgment of committal in termtime or in vacation. The affidavit shall state facts to establish: (a) the defendant is an alcoholic or drug addict, i.e., he is powerless over alcohol or drugs, or both, and his life has thereby become unmanageable; (b) defendant's mental and physical health, his continued family life or his position in the community are dependent on his treatment at a chemical dependency unit, alcohol and drug unit, outpatient house or another private treatment facility, or combination of facilities, providing treatment for chemically dependent persons; (c) the defendant has refused to commit himself to such private treatment facility, though having been requested so to do by persons who genuinely care for his well-being; (d) the affiant has selected a particular private treatment facility which, if located in this state, has been approved by the Department of Mental Health, Division of Alcohol and Drug Abuse; (e) the affiant has made adequate financial arrangements for defendant's treatment at such facility; and (f) such facility has approved the admission of the defendant, subject to commitment by the chancery court.