Michigan Supreme Court State Court Administrative Office Trial Court Services Division Michigan Hall of Justice P.O. Box 30048 Lansing, Michigan 48909 Phone (517) 373-4835 Jennifer Warner Director MEMORANDUM DATE: February 28, 2019 FROM: Rebecca A. Schnelz, Forms and Resources Analyst RE: Notice of Revisions to PCM Forms Multiple mental health forms have been revised to comply with statutory revisions. These revised forms must be used beginning, but not before, March 28, 2019. A brief explanation of the changes and a copy of each form with the changes highlighted are provided. Fillable versions of the forms will be posted to the SCAO website prior to their effective date. For questions, comments, or suggestions about these court forms, contact 517-373-5626 or [email protected]. PCM 201, Petition for Mental Health Treatment Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes. The form was revised to comply with 2018 PA 593. Options necessary to request an examination or transport (previously on PCM 209a) were added to the form. Additional changes were made for clarity.
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Michigan Supreme Court · Court ORI Date of birth Place of birth Race Sex PCS CODE: PFHPASAPM TCS CODE: IPFHPFHPASAPM XXX-XX-Do not write below this line For court use only STATE
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Michigan Supreme Court State Court Administrative Office
Trial Court Services Division Michigan Hall of Justice
P.O. Box 30048 Lansing, Michigan 48909
Phone (517) 373-4835
Jennifer Warner Director
MEMORANDUM
DATE: February 28, 2019
FROM: Rebecca A. Schnelz, Forms and Resources Analyst
RE: Notice of Revisions to PCM Forms
Multiple mental health forms have been revised to comply with statutory revisions. These revised forms must be used beginning, but not before, March 28, 2019. A brief explanation of the changes and a copy of each form with the changes highlighted are provided. Fillable versions of the forms will be posted to the SCAO website prior to their effective date.
For questions, comments, or suggestions about these court forms, contact 517-373-5626 or [email protected].
PCM 201, Petition for Mental Health Treatment Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593. Options necessary to request an examination or transport (previously on PCM 209a) were added to the form. Additional changes were made for clarity.
Notice of Revisions to PCM Forms February 28, 2019 Page 2
PCM 203, Objection to Administrative Admission (Individual with Developmental Disability) Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596. Additional changes were made to conform to standard formatting.
PCM 204, Notice of Hearing and Appointment of Attorney on Objection to Hospitalization or Administrative Admission Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596.
PCM 205, Order Following Hearing on Objection by Minor to Hospitalization/Administrative Admission Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596. Additional changes were made to conform to standard formatting.
PCM 208, Clinical Certificate Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
Notice of Revisions to PCM Forms February 28, 2019 Page 3
PCM 208a, Supplement to Clinical Certificate on Appeal of Return to Hospital/Facility Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596.
PCM 209a, Order for Examination/Transport *Completely Revised Form* Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was completely revised to accommodate and comply with 2018 PA 593. All information regarding a supplemental petition to request an examination or transport was removed and the remaining items renumbered. Language required to request and order the transport of an individual for an assisted outpatient evaluation was added. A Report of Non-Execution section was added for the use of law enforcement agencies.
PCM 214, Initial Order After Hearing on Petition for Mental Health Treatment Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
PCM 214a, Order Following Hearing on Petition for Judicial Admission Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596. Additional changes were made to conform with standard formatting.
Notice of Revisions to PCM Forms February 28, 2019 Page 4
PCM 215, Order for Report on Petition for Judicial Admission Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596. Additional changes were made to conform to standard formatting.
PCM 215a, Certification and Report on Petition for Judicial Admission Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596. Additional changes were made to conform to standard formatting.
PCM 216, Order and Report on Alternative Mental Health Treatment Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593. An additional change was made to correct the name of MDHHS.
PCM 217a, Order to Modify Order for Assisted Outpatient Treatment or Combined Hospitalization and Assisted Outpatient Treatment Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593. A use note regarding the form was added. Additional changes were made to conform to standard formatting.
Notice of Revisions to PCM Forms February 28, 2019 Page 5
PCM 218, Petition for Second or Continuing Mental Health Treatment Order Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
PCM 219, Second or Continuing Order for Mental Health Treatment Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
PCM 220, Petition for Discharge from Continuing Mental Health Treatment Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
PCM 220a, Petition for Discharge from Judicial Admission Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596.
Notice of Revisions to PCM Forms February 28, 2019 Page 6 PCM 222, Order After Hearing on Petition for Discharge from Continuing Mental Health Treatment Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
PCM 222a, Order Following Hearing on Petition for Discharge from Judicial Admission Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596.
PCM 224, Petition for Judicial Admission Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596. Additional changes were made to conform with standard formatting.
PCM 225, Order Dismissing Petition for Discharge from Judicial Admission Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596. Additional changes were made to conform with standard formatting.
Notice of Revisions to PCM Forms February 28, 2019 Page 7 PCM 226, Six-Month Review Report Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593 and 2018 PA 596.
PCM 227, Notice to Attorney of Return to Hospital/Facility from Authorized Leave Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596. Additional changes were made to comply with standard formatting.
PCM 230, Notification of Noncompliance and Request for Modified Order Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
PCM 231, Order for Report after Notification and Report Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593 and 2018 PA 596.
Notice of Revisions to PCM Forms February 28, 2019 Page 8
PCM 232, Order Following Hearing on Appeal of Return to Hospital/Facility from Authorized Leave Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593 and 2018 PA 596. Additional changes were made to conform to standard formatting.
PCM 233, Notice of Right to Appeal Return and Appeal of Return from Authorized Leave Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 596. Additional changes were made to conform to standard formatting.
PCM 235, Request to Defer Hearing on Commitment Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
PCM 236, Demand for Hearing Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019
Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
Notice of Revisions to PCM Forms February 28, 2019 Page 9 PCM 241, Notice of Right to Object to Hospitalization and Objection and Demand for Hearing Most recent update: (2/19) version Existing paper stock can be used until 3/28/2019 Click here to see the highlighted changes.
The form was revised to comply with 2018 PA 593.
PCM 245, Notice of Inability to Secure Evaluation/Examination *New Form* Click here to see the highlighted changes.
A new form was created to accommodate changes in procedure pursuant to 2018 PA 593.
Approved, SCAO
In the matter of First, middle, and last name
Last four digits of SSN
Court ORI Date of birth Place of birth Race Sex
PCS CODE: PFH/PAS/APMTCS CODE: IPFH/PFH/PAS/APM
XXX-XX-
Do not write below this line - For court use only
STATE OF MICHIGANPROBATE COURTCOUNTY OF
PETITION FOR MENTAL HEALTH TREATMENT
AMENDED
FILE NO.
PCM 201 (2/19) PETITION FOR MENTAL HEALTH TREATMENTMCL 330.1100a(29), MCL 330.1401, MCL 330.1423, MCL 330.1427,
USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.(SEE SECOND PAGE)
1. I, Name (type or print)
, an adult specify whether a relative, neighbor, peace officer, etc.
petition because
I believe the individual named above needs treatment.
2. The individual was born Date
, has a permanent residence in
County at
Street address City State ZIP
and can presently be found at Facility name or other address
. This petition is for a person who was found not guilty by reason of insanity in this county (NGRI).
3. I believe the individual has mental illness and a. as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or unintentionally seriously physically injure self or others, and has engaged in an act or acts or made significant threats that are substantially supportive of this expectation.
b. as a result of that mental illness, the individual is unable to attend to those basic physical needs that must be attended to in order to avoid serious harm in the near future, and has demonstrated that inability by failing to attend to those basic physical needs.
c. the individual's judgment is so impaired by that mental illness, and whose lack of understanding of the need for treatment has caused him or her to demonstrate an unwillingness to voluntarily participate in or adhere to treatment that is necessary, on the basis of competent clinical opinion, to prevent a relapse or harmful deterioration of his or her condition, and presents a substantial risk of significant physical or mental harm to the individual or others.
4. The conclusions stated above are based on a. my personal observation of the person doing the following acts and saying the following things:
b. the following conduct and statements that others have seen or heard and have told me about:
by: Witness name Complete address Telephone no.
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Petition for Mental Health Treatment (2/19) File No.
5. The persons interested in these proceedings are:NAME RELATIONSHIP ADDRESS TELEPHONE
Spouse
Guardian*
*(Specify the county where the guardianship was established and the case number.)
6. The individual is is not a veteran.
7. Attached is a clinical certificate by a physician or licensed psychologist taken within the last 72 hours. clinical certificate by a psychiatrist taken within the last 72 hours. no clinical certificate is attached because only assisted outpatient treatment is requested.
8. An examination could not be secured because
I request: a. the individual be examined at
,
the preadmission screening unit or hospital designated by the community mental health services program. b. a peace officer take the individual into protective custody and transport the individual to
.
9. I request the court to determine the individual to be a person requiring treatment and a. order appropriate mental health treatment including hospitalization or a combination of hospitalization and assisted outpatient treatment. b. order that the individual participate in assisted outpatient treatment without hospitalization.
10. I request the individual be hospitalized pending a hearing.
I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Signature of attorney
Date
Name (type or print) Bar no.
Signature of petitioner
Address
Address
City, state, zip Telephone no.
City, state, zip
Home telephone no.
Work telephone no.
FOR HOSPITAL USE ONLY
This petition for mental health treatment was received by the hospital on Date
at Time
.
Signature of hospital representative
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PCM 203 (2/19) OBJECTION TO ADMINISTRATIVE ADMISSION (INDIVIDUAL WITH DEVELOPMENTAL DISABILITY)MCL 330.1511
Approved, SCAO JIS CODE: OBJ
STATE OF MICHIGANPROBATE COURTCOUNTY OF
OBJECTION TO ADMINISTRATIVEADMISSION (INDIVIDUAL WITHDEVELOPMENTAL DISABILITY)
FILE NO.
USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
In the matter of
, an individual with a developmental disability
1. I object to the administrative admission of Name
and request the
court to schedule a hearing on this objection. This objection is made
within 30 days after the admission of the resident.
after the first objection or six months after a prior objection.
Date
Signature
2. The person filing this objection is
the resident. I am age 13 or older.
Name
Relationship or reason interested in resident
Address City State Zip
Telephone no.
3. The resident was administratively admitted to
Name of facility
on Date
upon the application of Name
,
Address City State Zip
Telephone no.
,
who is the resident’s parent. guardian. person in loco parentis.
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PCM 204 (2/19) NOTICE OF HEARING AND APPOINTMENT OF ATTORNEY ON OBJECTION TO HOSPITALIZATION OR ADMINISTRATIVE ADMISSION MCL 330.1475a, MCL 330.1498n, MCL 330.1511, MCR 5.744(D)
Approved, SCAO JIS CODE: NOH
STATE OF MICHIGANPROBATE COURTCOUNTY OF
NOTICE OF HEARING AND APPOINTMENTOF ATTORNEY ON OBJECTION TO
HOSPITALIZATION ORADMINISTRATIVE ADMISSION
FILE NO.
In the matter of
1. This court has received your objection to hospitalization/admission without a hearing and will conduct a hearing to decide whether you need to be in a hospital or facility. If this court agrees, you will be allowed to leave.
2. A hearing on your objection will be held at:
Location
Date Time
before Judge Bar no.
3. You are entitled to be represented by an attorney. The court has appointed:
Attorney name Bar no.
Address
City, state, zip Telephone no.
If you desire to employ an attorney of your own choice, you may do so. If you prefer an attorney other than the one appointed for you, and the preferred attorney agrees to accept the employment and notifies the court of his/her appearance on your behalf, the court will replace the attorney now appointed for you. If you feel you are unable to pay for an attorney, and the court agrees, the court will see that your attorney is paid from public funds at the court approved rate.
4. You have the right to be present at the hearing. If you fail to attend the hearing after having an opportunity to meet with your attorney, you will be considered to have waived your right to attend and the hearing may be held without you.
5. For administrative admission only (applies to individuals with developmental disability): You may also ask for an independent medical or psychological evaluation. If you feel you are unable to pay for this, and the court agrees, the court will see that the evaluation is paid for from public funds. You should discuss the need for an independent medical or psychological evaluation with your attorney.
6. You should discuss your rights with your attorney.
Date
Deputy probate register/clerk
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PCM 205 (2/19) ORDER FOLLOWING HEARING ON OBJECTION BY MINOR TO HOSPITALIZATION / ADMINISTRATIVE ADMISSION MCL 330.1498n, MCL 330.1511
Approved, SCAO JIS CODE: OOJ
STATE OF MICHIGANPROBATE COURTCOUNTY OF
ORDER FOLLOWING HEARING ONOBJECTION BY MINOR TO
HOSPITALIZATION/ADMINISTRATIVE ADMISSION
FILE NO.
USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
In the matter of First, middle, and last name
1. Date of hearing:
Judge: Bar no.
2. Name
has filed an objection to the
hospitalization of the minor named above at Hospital name
.
administrative admission of the resident named above to Facility name
.
3. Notice of the hearing was given to or waived by all interested persons. was present in court. with4. The individual was not present for reasons stated on the record. The hearing was without a jury.
Present were
, the attorney for the individual, and
, the attorney for the petitioner.
5. Testimony was given by
. Testimony was waived and the parties stipulated to the entry of the order.
THE COURT FINDS:
6. There is is not clear and convincing evidence that the minor is suitable for hospitalization.
7. The resident is not in need of the care and treatment that is available at the facility.
8. An alternative to the care and treatment provided in the facility is available and adequate to meet the resident’s needs.
9. The resident is in need of care and treatment that is available at the facility and there is no alternative to care and treatment provided in the facility that is available and adequate to meet the needs of the resident. No order sustaining the objection will be entered.
IT IS ORDERED:
10. The objection is sustained, and the minor/resident is discharged from the hospital/facility. 11. The objection is denied on the merits and the minor/resident shall remain at the hospital/facility. 12. The objection is dismissed/withdrawn.
Date
Judge
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use only
(SEE SECOND PAGE)
STATE OF MICHIGANPROBATE COURTCOUNTY OF CLINICAL CERTIFICATE
TO THE EXAMINER: The following is a statement that must be read to the individual before proceeding with any questions.
I am authorized by law to examine you for the purpose of advising the court if you have a mental condition which needs treatment and whether such treatment should take place in a hospital or in some other place. I am also here to determine if you should be hospitalized or remain hospitalized before a court hearing is held. I may be required to tell the court what I observe and what you tell me. 1. I am a psychiatrist. licensed psychologist. physician.
2. I certify that on this date I read the above statement to the individual before asking any questions or conducting any examination.
3. I further certify that I, Name (type or print)
, personally examined Patient
at Name and address where examination took place
on Date
starting at Time
and continuing for
minutes.
INSTRUCTIONS: Describe in detail the specific actions, statements, demeanor, and appearance of the individual, together with other information which underlie your conclusion. Indicate the source of any information not personally known or observed. If this certificate is to accompany a petition for discharge, state why the individual continues to be or is no longer a person requiring treatment or in need of hospitalization.
4. My determination is that the person is mentally ill (has a substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life). not mentally ill.
5. (if applicable) The person has convulsive disorder. alcoholism. other drug dependence. mental processes weakened by reason of advanced years. other (specify):
6. My diagnosis is:
7. Facts serving as the basis for my determination are:
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Clinical Certificate (2/19) File No.
8. Explain in the space below the facts which lead you to believe that future conduct may result in (check applicable box) a. likelihood of injury to self. Facts:
Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near future to intentionally or unintentionally seriously physically injure self.
b. likelihood of injury to others. Facts:
Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near future to intentionally or unintentionally seriously physically injure others.
c. inability to attend to basic physical needs. Facts:
Therefore, I believe that the examined person, as a result of mental illness, is unable to attend to those basic physical needs (such as food, clothing or shelter) that must be attended to in order to avoid serious harm in the near future and has demonstrated that inability by failing to attend to those basic physical needs.
d. inability to understand need for treatment. Facts:
Therefore, I believe that the examined person, as a result of mental illness, is so impaired by that mental illness and whose lack of understanding of the need for treatment has caused him or her to demonstrate an unwillingness to voluntarily participate in or adhere to treatment that is necessary, on the basis of competent clinical opinion, to prevent a relapse or harmful deterioration of his or her condition, and presents a substantial risk of significant physical or mental harm to himself/herself or others.
9. I conclude the individual is is not a person requiring treatment.
10. (optional) I recommend hospitalization assisted outpatient treatment
as follows:
.
I certify that I am a person authorized by law to certify as to the individual's mental condition. I am not related by blood or marriage either to the person about whom this certificate is concerned or to any person who has filed, or whom I know to be planning to file, a petition in this proceeding. I declare under the penalties of perjury that this certificate has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date
Time of signing
Signature
Print or type name and business telephone no.
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use only
STATE OF MICHIGANPROBATE COURTCOUNTY OF
SUPPLEMENT TO CLINICAL CERTIFICATEON APPEAL OF RETURN TO
HOSPITAL/FACILITY
FILE NO.
PCM 208a (2/19) SUPPLEMENT TO CLINICAL CERTIFICATE ON APPEAL OF RETURN TO HOSPITAL/FACILITYMCR 5.743a
PCS CODE: PCATCS CODE: PCA
Attached is my clinical certificate (form PCM 208) setting forth why the above person requires treatment. I further certify and report as follows.
1. The reason(s) for this individual's return to the hospital or facility from authorized leave, and the need for treatment in a hospital or facility are
2. The plans for further treatment of the individual are
3. Should the court rule against the return of this individual, I recommend the court consider the following alternatives instead of a return to authorized leave status, if any of these options are available. Day treatment in a hospital or facility Night treatment in a hospital or facility Residential placement Custody of a friend or relative Inpatient treatment at a private psychiatric hospital, Assisted outpatient treatment at a general hospital's psychiatric unit, or a private Home care or homemaker service residential facility Day activity programs
Other:
None of the above merits exploration. State reasons
I declare under the penalties of perjury that this certificate has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date
Signature
Title (physician, psychiatrist, licensed psychologist)
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Approved, SCAO
In the matter of First, middle, and last name
DOB:
Do not write below this line - For court use only
STATE OF MICHIGANPROBATE COURTCOUNTY OF
ORDER FOR EXAMINATION/TRANSPORT
FILE NO.
PCM 209a (2/19) ORDER FOR EXAMINATION/TRANSPORT MCL 330.1435, MCL 330.1436, MCL 330.1437, MCL 330.1438
PCS CODE: OET TCS CODE: OET
1. Date of hearing:
Judge: Bar no.
THE COURT FINDS:2. A petition alleging the individual is a person requiring treatment and requesting hospitalization or a combined treatment order has been filed with the court, and a. one clinical certificate accompanies the petition. The individual must be examined by a psychiatrist. b. no clinical certificate accompanies the petition. A reasonable effort was made to secure an examination. The individual must be examined by a psychiatrist and either a physician or a licensed psychologist.
3. The court has received information that a petition for assisted outpatient treatment has been filed, the petitioner has made reasonable efforts to secure an examination, and the individual will not make himself/herself available for evaluation.
4. The individual requires immediate assessment because the individual presents a substantial risk of significant physical or mental harm to himself/herself in the near future or presents a substantial risk of significant physical harm to others in the near future.
5. There does not appear to be probable cause to order the individual be taken into protective custody and transported to the designated prescreening unit or hospital. IT IS ORDERED:
6. The individual be examined by a psychiatrist. psychiatrist and a physician or licensed psychologist at
Prescreening unit or hospital .
Upon completion of the examination(s), the executed clinical certificate(s) shall be filed with the court or a report that a clinical certificate is not warranted shall be made to the court.
The individual shall be hospitalized. If the examinations and clinical certificates are not completed within 24 hours after hospitalization, the individual shall be released.
A peace officer shall take the individual into protective custody and transport him/her to the designated prescreening unit or hospital. If the order is not executed by
10 days from entry of order, the law enforcement
agency must report to the court the reason the order was not executed within the prescribed time period.
7. A peace officer shall take the individual into protective custody and transport him/her to the designated prescreening unit or hospital for assessment for assisted outpatient treatment. If the order is not executed by
10 days from entry of order, the law enforcement agency must report to the court the reason the order
was not executed within the prescribed time period.
8. The request to take the individual into protective custody for transport is denied.
Date
Judge Bar no.
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Completely Revised Form
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Order for Examination/Transport (2/19) File No.
The Order for Examination/Transport issued on Date
has not been executed. The reason the order was
not executed within 10 days after entry is:
Date
Name
Law enforcement agency
Telephone no.
TO THE LAW ENFORCEMENT AGENCY: Under MCL 330.1436(2), this report must be filed with the court that issued the Order for Examination/Transport if the order is not executed within 10 days after entry of the order.
REPORT OF NON-EXECUTION
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Do not write below this line - For court use only(SEE SECOND PAGE)
STATE OF MICHIGANPROBATE COURTCOUNTY OF
INITIAL ORDER AFTER HEARING ON PETITION FOR
MENTAL HEALTH TREATMENT
FILE NO.
PCM 214 (2/19) INITIAL ORDER AFTER HEARING ON PETITION FOR MENTAL HEALTH TREATMENTMCL 330.1401, MCL 330.1464a, MCL 330.1465, MCL 330.1468, MCL 330.1469a, MCL 330.1470,
above is a person requiring treatment.THE COURT FINDS:3. Notice of hearing has been given according to law. 4. The individual was present in court. was not present for reasons stated on the record. The hearing was with withoutajury.
8. There is is not an available treatment program that is an alternative to hospitalization or that follows an initialperiodofhospitalizationadequatetomeettheindividual'streatmentneedsandissufficienttopreventharmthatthe individualmayinflictuponselforotherswithinthenearfuture.
9.
hospital can provide treatment, which is adequate and appropriate to the individual’s condition.
10. The individual is not a person requiring treatment.
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Initial Order After Hearing on Petition for Mental Health Treatment (2/19) File No.
IT IS ORDERED:11. Anyhospitalizationoftheindividualformentalhealthtreatmentshalloccurinthehospitallistedinitem9.
12. The individual be hospitalized for up to 1to60days
b.thepatienttobereleasedordischargedshallundergoacompetencyexaminationasdescribedinMCL330.2026.Acopy of the written report of the examination along with the notice required in item 18a above shall be submitted to the prosecutor'sofficeinthecountyinwhichthechargesagainstthepatientwereoriginallybrought.Thewrittenreportis admissibleasprovidedinMCL330.2030(3).
Date
Judge
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PCM 214a (2/19) ORDER FOLLOWING HEARING ON PETITION FOR JUDICIAL ADMISSION
ORDER FOLLOWING HEARING ON PETITION FOR JUDICIAL ADMISSION
FILE NO.
(PLEASE SEE OTHER SIDE)
In the matter of First, middle, and last name
1. Date of hearing:
Judge: Bar no.
2. A petition has been filed by Petitioner name (type or print)
asserting that the individual
named above meets the criteria for judicial admission for treatment and that the court should order the individual to be admitted to a facility.
3. The court finds that notice of hearing has been given according to law. The parties were present.
4. The hearing was with without a jury.
5. The court received and considered the report on the petition for judicial admission for treatment.
6. Testimony was given by
.
THE COURT FINDS:
7. The individual is an adult, has been diagnosed as an individual with an intellectual disability, and a. can be reasonably expected within the near future to intentionally or unintentionally seriously physically injure self or others, and has overtly acted in a manner substantially supportive of that expectation. b. the individual has been arrested and charged with an offense that was a result of the intellectual disability.
8. There is is not an available program of care and treatment other than admission to a facility adequate to meet the individual’s care and treatment needs and that is sufficient to prevent harm or injury which the individual may inflict upon self or others.
9.
facility can provide the individual with the care and treatment adequate and appropriate for his/her condition in the least restrictive environment located nearest to his/her residence.
10. The individual or a relative requested that the individual be admitted to
, a private licensed hospital that complies with the duties and requirements for facilities, and has agreed to pay the costs with private funds.
11. The individual does not meet the criteria for judicial admission for treatment.
IT IS ORDERED:12. The petition is granted. denied on the merits. dismissed/withdrawn.
13. The individual be admitted to
a. a facility designated by the department and recommended by the community mental health services program.
b. Name of licensed hospital
, which has accepted the individual.
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Order Following Hearing on Petition for Judicial Admission (2/19) File No.
14. The individual undergo alternative care and treatment for a period not to exceed one year. Alternative treatment shall be under the supervision of
as follows:
If previously admitted to a facility, the individual shall be discharged.
15. If a resident is discharged by the director of a facility under MCL 330.1525(1) or (2), the facility must notify the court and community mental health services program. If a resident met the criteria for treatment under MCL 330.1515(b), the prosecuting attorney must also be notified of the discharge by a facility.
16. If felony charges have been previously dismissed under MCL 330.2044(1)(b) and the time for petitioning to refile charges has not elapsed,
a. not less than 30 days before the resident’s scheduled release or discharge, the director of the treating facility shall notify the prosecutor’s office in the county in which charges against the resident were originally brought that the resident’s release or discharge is pending.
b. not less than 30 days before the resident’s scheduled release or discharge, the resident shall undergo a competency examination as described in MCL 330.2026. A copy of the written report of the examination along with the notice required in item 16a above shall be submitted to the prosecutor’s office in the county in which the charges against the resident were originally brought. The written report is admissible as provided in MCL 300.2030(3).
Date
Judge
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PCM 215 (2/19) ORDER FOR REPORT ON PETITION FOR JUDICIAL ADMISSION MCL 330.1516
Approved, SCAO JIS CODE: ORT
STATE OF MICHIGANPROBATE COURTCOUNTY OF
ORDER FOR REPORT ONPETITION FOR JUDICIAL ADMISSION
FILE NO.
In the matter of First, middle, and last name
THE COURT FINDS:
1. A petition for judicial admission for treatment has been filed and it appears on its face to be sufficient.
2. The individual must be examined and a report filed.
3. The individual will not comply with an order for examination and a peace officer must take him/her into protective custody and transport him/her to the place of examination.
IT IS ORDERED:
4. The individual be examined at
5. Name
is appointed to arrange for the examination of
the individual and to prepare and file a report to the court.
6. A peace officer take the individual into protective custody and transport him/her immediately to the site designated above
where the individual may remain up to 48 hours for the required examinations. The transport order is valid through
Date .
Date
Judge Bar no.
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PCM 215a (2/19) CERTIFICATION AND REPORT ON PETITION FOR JUDICIAL ADMISSION MCL 330.1516, MCR 5.741
Approved, SCAO JIS CODE: CJA
STATE OF MICHIGANPROBATE COURTCOUNTY OF
CERTIFICATION AND REPORT ONPETITION FOR JUDICIAL ADMISSION
FILE NO.
(PLEASE SEE OTHER SIDE)
In the matter of First, middle, and last name
On Date
, I examined the individual and report that:
1. The individual does does not meet the criteria for treatment.2. My diagnosis is that the individual does does not have an intellectual disability.3. The individual a. can cannot be reasonably expected within the near future to intentionally or unintentionally seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation. b. has been arrested and charged with an offense that was a result of the intellectual disability.
I base my conclusion on the following facts:
4. The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending hearing.
Date
Signature
Name and title
On Date
, I examined the individual and report that:
1. The individual does does not meet the criteria for treatment.2. My diagnosis is that the individual does does not have an intellectual disability.3. The individual a. can cannot be reasonably expected within the near future to intentionally or unintentionally seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation. b. has been arrested and charged with an offense that was a result of the intellectual disability.
I base my conclusion on the following facts:
4. The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending hearing.
Date
Signature
Name and title
CERTIFICATION OF EXAMINERS
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Certification and Report on Petition for Judicial Admission (2/19) File No.
1. I, Name
, as Profession, organization, and title
,
have met with and evaluated the individual and report that his/her mental, physical, social, and educational condition is:
2. The following is a list of available forms of care and treatment that may serve as an alternative to admission to a facility.
a. Residential placement:
Availability (specify):
b. Day activity programs:
Availability (specify):
c. Outpatient treatment:
Availability (specify):
d. Custody of friend or relative:
Availability (specify):
e. Home care or homemaker services:
Availability (specify):
f. Inpatient treatment at private psychiatric hospital: Name of hospital
Availability (specify):
g. Other:
Availability (specify):
3. I recommend the most appropriate living arrangement for the individual in terms of type and location and the availability of
support services to be
.
I declare under the penalties of perjury that this report has been examined by me and that its contents are true to the best ofmy information, knowledge, and belief.
Date
Address
Signature
City, state, zip Telephone no.
REPORT ON PETITION FOR JUDICIAL ADMISSION
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use only(SEE SECOND PAGE)
STATE OF MICHIGANPROBATE COURTCOUNTY OF
ORDER AND REPORT ONALTERNATIVE MENTAL HEALTH TREATMENT
FILE NO.
PCM 216 (2/19) ORDER AND REPORT ON ALTERNATIVE MENTAL HEALTH TREATMENT MCL 330.1453a, MCR 5.741
PCS CODE: ORA/RATTCS CODE: ORA/RAT
IT IS ORDERED that Name (type or print)
shall prepare a report assessing the current
availability and appropriateness of alternatives to hospitalization for the individual named above including alternatives availablefollowing an initial period of court-ordered hospitalization.
The report shall be made to the court before the hearing on Date and time of hearing
for
Petition for 60-day order, discharge, etc. .
Date
Judge Bar no.
1. I, Name
, as Profession, organization, and position
, report as follows.
2. I have reviewed, as to their availability in or near the individual’s home community, treatment resources alternative to hospitalization and report as follows: (If practical, give name of agency, program, etc.)
a. Independent mental health professional:
b. Community mental health day treatment, aftercare service, work activity, or other program:
c. Substance abuse, rehabilitation service, or similar program of public or private agency:
d. Other:
ORDER
REPORT ON EVALUATION OF HOSPITAL TREATMENT AND/OR ALTERNATIVE PROGRAMS
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Order and Report on Alternative Mental Health Treatment (2/19) File No.
3. I have reviewed, as to their availability in or near the individual's home community, residential accommodations and report as follows: (If practical, give name of residence, location, etc.) a. Independent:
Individual’s own house, apartment, etc.
b. Residence of relative or friend:
c. Foster care home:
d. Nursing home:
e. Other:
4. I recommend release.
5. I recommend a course of treatment of hospitalization hospitalization for
days, followed by
assisted outpatient treatment as follows:
6. My recommendation is based upon the following described interviews, observations, and information:
7. I believe the hospital to which admission is proposed can cannot provide its prescribed treatment program appropriately and adequately because
8. I recommend the following agency or independent mental health professional to supervise the outpatient treatment:
Name Complete address
The agency or professional has has not indicated capability and willingness to supervise the recommended program.
9. The individual currently has the following source(s) of funds to cover his or her care in the community:
a. Application for supplemental funds has been made. They should be available
. b. Application for supplemental funds has not been made because
.
Application will be made on
and should be available about
. c. Pending receipt of supplemental funds, the following funds will be available: Direct relief. MDHHS/CMH emergency care funds. Other assistance:
None. Reason:
Date
Signature
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use only
(SEE SECOND PAGE)USE NOTE: Use form PCM 244 to modify an order for assisted outpatient treatment or an order for combined hospitalization and assisted outpatient treatment under MCL 330.1475(3)-(5).
STATE OF MICHIGANPROBATE COURTCOUNTY OF
ORDER TO MODIFY ORDER FOR ASSISTED OUTPATIENT TREATMENT
OR COMBINED HOSPITALIZATION AND ASSISTED OUTPATIENT TREATMENT
FILE NO.
PCM 217a (2/19) ORDER TO MODIFY ORDER FOR ASSISTED OUTPATIENT TREATMENT OR COMBINED HOSPITALIZATION AND ASSISTED OUTPATIENT TREATMENT
MCL 330.1475(1), (2), MCR 5.744
PCS CODE: C9MTCS CODE: C9M
1. Date of hearing (if one):
Judge: Bar no.
2. This court issued an initial second continuing order on Date
directing the individual
named above to undergo a program of assisted outpatient treatment or combined hospitalization and assisted outpatient treatment.
3.Thecourthasbeennotifiedthat the individual is not complying with the order for assisted outpatient treatment or combined hospitalization and assisted outpatient treatment. assistedoutpatienttreatmenthasnotbeenorwillnotbesufficienttopreventharmtheindividualmayinflictupon self or others. the individual believes that the assisted outpatient treatment program is not appropriate.
4. THE COURT FINDS:
IT IS ORDERED:
5.Theorderforassistedoutpatienttreatmentorcombinedhospitalizationandassistedoutpatienttreatmentismodifiedand the individual shall undergo a program of assisted outpatient treatment under the supervision of a community mental health services program
a mental health agency or professional
as follows:
This assisted outpatient treatment shall not exceed the time from the date of issuance of the initial second continuing combined order.
6.Theorderforassistedoutpatienttreatmentorcombinedhospitalizationandassistedoutpatienttreatmentismodifiedand the individual shall be hospitalized at
for a period not to exceed the remainder of the previously-ordered hospitalization portion of the initial second continuing combined order.
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Order to Modify Order for Assisted Outpatient Treatment or Combined Hospitalization and Assisted Outpatient Treatment (2/19)
File No.
7.Theorderforassistedoutpatienttreatmentorcombinedhospitalizationandassistedoutpatienttreatmentismodifiedand the individual shall continue to undergo combined hospitalization and assisted outpatient treatment for the remainder of the previously-ordered period. The individual shall be hospitalized at
for a period not to exceed the remainder of the initially ordered hospitalization portion of the initial second continuing combined order. Assisted outpatient treatment shall be under the supervision of a community mental health services program
8.Iftheindividualrefusestocomplywithapsychiatrist’sordertoreturntothehospital,apeaceofficershalltakethe individual into protective custody and transport the individual to the hospital designated by the psychiatrist. 9. This order expires on
Date .
Date
Judge
If the court has ordered you to be hospitalized rather than continue in an assisted outpatient treatment program you have a right to object to this hospitalization. If you wish to object, complete the objection below and send a copy to the court.
I certify that this notice was personally served on the individual named above on Date
at Time
and a copy was mailed to the
Court on Date
.
Signature
I object to my hospitalization and request that the court schedule a hearing on the objection.
Date
Signature
NOTICE OF RIGHT TO OBJECT TO HOSPITALIZATION
PROOF OF SERVICE
OBJECTION TO HOSPITALIZATION
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Approved, SCAO
In the matter of First, middle, and last name
DOB:
Do not write below this line - For court use only
STATE OF MICHIGANPROBATE COURTCOUNTY OF
PETITION FOR SECOND CONTINUING
MENTAL HEALTH TREATMENT ORDER
FILE NO.
PCM 218 (2/19) PETITION FOR SECOND OR CONTINUING MENTAL HEALTH TREATMENT ORDERMCL 330.1472a(5),
MCL 330.1473
USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
(SEE SECOND PAGE)
PCS CODE: PCT/PCOTCS CODE: PSO/PCO
1. I, Name (type or print)
, state that I am
the authorized representative of the agency or mental health professional supervising the individual’s assisted outpatient treatment program.
Director or authorized representative of
Name of hospital .
2. The individual is currently residing hospitalized at Address and telephone no.
.
3. The initial second continuing order entered by this court for the individual expires on Date
.
4. The individual continues to be a person requiring treatment and is in need of hospitalization for not more than 90 days. continuing hospitalization for a period of one year. combined hospitalization and assisted outpatient treatment for not more than one year. assisted outpatient treatment for not more than one year.
5. The individual is likely to refuse treatment on a voluntary basis when the order expires.
INSTRUCTIONS: In answering items 6 and 7, include a description of the observed or reported behavior of the individual including, but not limited to, how behavior and conditions have changed since the last order and whether any stabilization or remission is contingent on continued medication or other treatment. Avoid medical terms and conclusions other than diagnosis.
6. The basis for this allegation is that I believe the individual has a mental illness and: (Check all that apply.) a. as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or unintentionallyseriouslyphysicallyinjureselforothers,andhasengagedinanactoractsormadesignificantthreats that are substantially supportive of this expectation. b. as a result of that mental illness, the individual is unable to attend to those basic physical needs that must be attended to in order to avoid serious harm in the near future, and has demonstrated that inability by failing to attend to those basic physical needs. c. the individual’s judgment is so impaired by that mental illness and whose lack of understanding of the need for treatment has caused him or her to demonstrate an unwillingness to voluntarily participate in or adhere to treatment that is necessary, on the basis of competent clinical opinion, to prevent a relapse or harmful deterioration ofhisorhercondition,andpresentsasubstantialriskofsignificantphysicalormentalharmtotheindividualorothers.
7. This conclusion is based upon a. my personal observation of the person doing the following acts and saying the following things:
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Petition for Second or Continuing Mental Health Treatment Order (2/19) File No.
b. the following conduct and statements that others have seen or heard and have told me about:
by:
Witness name Complete address Telephone no.
8. The diagnoses of physical and mental conditions are
. 9. The treatment program(s) provided to the individual thus far, and the results, are
.
10. The present treatment is is not adequate and appropriate to the individual's condition. The individual is is not motivated to participate in this treatment program. The estimate of further time necessary to provide the required treatment is
13. I REQUEST the court to order the individual to receive hospitalization for not more than 90 days. continuing hospitalization for not more than one year. combined hospitalization and assisted outpatient treatment for not more than 90 days one year. assisted outpatient treatment for not more than 90 days one year.
I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date
Signature of petitioner
Address
City, state, zip Telephone no.
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Approved, SCAO
STATE OF MICHIGANPROBATE COURTCOUNTY OF
SECOND CONTINUING ORDER FOR MENTAL HEALTH TREATMENT
FILE NO.
PCM 219 (2/19) SECOND OR CONTINUING ORDER FOR MENTAL HEALTH TREATMENT
THE COURT FINDS:3. Notice of hearing has been given according to law. 4. The individual was present in court. was not present for reasons stated on the record. The hearing was with without ajury.
8. There is is not an available treatment program that is an alternative to hospitalization or that follows an initial periodofhospitalizationadequate tomeet the individual's treatmentneedsand is sufficient topreventharm that the individualmayinflictuponselforotherswithinthenearfuture.
9.
hospital can provide treatment thatisadequateandappropriatetotheindividual'scondition.
10. The individual is not a person requiring treatment.
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Second or Continuing Order for Mental Health Treatment (2/19) File No.
IT IS ORDERED:11. Anyhospitalizationoftheindividualformentalhealthtreatmentshalloccurinthehospitallistedinitem9.
12. a. (Forasecondorder)The individual be hospitalized for up to 1to90days
days.
b. (Foracontinuingorder) The individual be hospitalized for up to 1to365days
days.
13. The individual receive assisted outpatient treatment for no longer than:
b.thepatienttobereleasedordischargedshallundergoacompetencyexaminationasdescribedinMCL330.2026.Acopy of the written report of the examination along with the notice required in item 17a above shall be submitted to the prosecutor'sofficeinthecountyinwhichthechargesagainstthepatientwereoriginallybrought.Thewrittenreportis admissibleasprovidedinMCL330.2030(3).
Date
Judge
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use onlyUSE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
STATE OF MICHIGANPROBATE COURTCOUNTY OF
PETITION FOR DISCHARGE FROM CONTINUING MENTAL HEALTH TREATMENT
FILE NO.
PCM 220 (2/19) PETITION FOR DISCHARGE FROM CONTINUING MENTAL HEALTH TREATMENTMCL 330.1483, MCL 330.1484
PCS CODE: DIPTCS CODE: DIP
1. I, Name (type or print)
, state that the individual is subject to a one-year order
of involuntary mental health treatment and I am
the executive director of the community mental health services program for the county of residence of the individual. hospitalized in
Name of hospital .
under a one-year assisted outpatient or a one-year combined treatment order under the supervision of
.
2. I object to the conclusion(s) in the periodic review report of Name of patient/resident
dated
and filed with this court. The individual named in that report is not a person requiring continuing involuntary mental health treatment and should be discharged from the program. 3. The interested parties, their addresses, and their representatives are identical to those appearing on the initial petition, except as follows:
4. I REQUEST that the court set a hearing and order a discharge.
I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date
Signature of petitioner
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PCM 220a (2/19) PETITION FOR DISCHARGE FROM JUDICIAL ADMISSION MCL 330.1531
Approved, SCAO JIS CODE: PDJ
STATE OF MICHIGANPROBATE COURTCOUNTY OF
PETITION FOR DISCHARGEFROM JUDICIAL ADMISSION
FILE NO.
In the matter of First, middle, and last name
1. I, Name (type or print)
, state that I am
a resident a person acting on behalf of a resident in Name of facility
.
2. I object to the conclusion(s) in the periodic review report of Name of resident
dated
and filed with this court. The individual named in that report does not meet the criteria
for judicially ordered treatment as prescribed by MCL 330.1531(3).
3. The interested parties, their addresses, and their representatives are identical to those appearing on the initial petition, except as follows:
4. I REQUEST that the court set a hearing and order a discharge.
I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the bestof my information, knowledge, and belief.
Date
Signature of petitioner
USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use only(SEE SECOND PAGE)
STATE OF MICHIGANPROBATE COURTCOUNTY OF
ORDER AFTER HEARINGON PETITION FOR DISCHARGE FROM
CONTINUING MENTAL HEALTH TREATMENT
FILE NO.
PCM 222 (2/19) ORDER AFTER HEARING ON PETITION FOR DISCHARGE FROM CONTINUING MENTAL HEALTH TREATMENT MCL 330.1485a, MCR 5.747
6.Theindividualisunderaone-yearorderofinvoluntarymentalhealthtreatment. 7. a. There is clear and convincing evidence that the individual has a mental illness and continues to require treatment. b. The individual no longer is a person requiring treatment.
8.
hospital can provide treatment that is adequate and appropriate to the individual’s condition.
IT IS ORDERED:
9. The individual is discharged from
hospital and/or from the treatment program. 10.Theorderrequiringinvoluntarymentalhealthtreatmentbecontinued.
PCM 222a (2/19) ORDER FOLLOWING HEARING ON PETITION FOR DISCHARGE FROM JUDICIAL ADMISSION MCR 5.747
Approved, SCAO JIS CODE: ODJ
STATE OF MICHIGANPROBATE COURTCOUNTY OF
ORDER FOLLOWING HEARINGON PETITION FOR DISCHARGE
FROM JUDICIAL ADMISSION
FILE NO.
In the matter of First, middle, and last name
1. Date of hearing:
Judge: Bar no.
2. A petition has been filed by Petitioner name (type or print)
requesting that the individual named
above be discharged from judicially ordered treatment.
THE COURT FINDS:
3. Notice of hearing has been given according to law.
4. The individual was present in court. with was not present for reasons stated on the record. The hearing was without a jury.
Present were
, the attorney for the individual, and
, the attorney for the hospital.
5. Testimony was given by
Testimony was waived and the parties consented to entry of the order.
6. a. The individual continues to meet the criteria for judicially ordered treatment.
b. The individual no longer is a person requiring judicially ordered treatment.
IT IS ORDERED:
7. The individual be discharged from judicially ordered treatment.
8. The order requiring treatment be continued.
Date
Judge
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PCM 224 (2/19) PETITION FOR JUDICIAL ADMISSION MCL 330.1516
Approved, SCAO JIS CODE: PJA
STATE OF MICHIGANPROBATE COURTCOUNTY OF PETITION FOR JUDICIAL ADMISSION
FILE NO.
USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
In the matter of First, middle, and last name
Last four digits of SSN
1. I, Name (type or print)
, am interested in this matter and make this petition as
State your interest/relationship
.
2. The individual named above, born Date
, is a resident of County
,
Michigan, and can be found at Address City State Zip
.
3. The individual is a person with an intellectual disability and a. can be reasonably expected within the near future to intentionally or unintentionally seriously physically injure self or another person and has overtly acted in a manner substantially supportive of that expectation. b. has been arrested and charged with an offense that was a result of the intellectual disability.
4. This allegation is based upon:
a. My personal observation of the individual doing the following acts and saying the following things:
(PLEASE SEE OTHER SIDE)
XXX-XX-
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Petition for Judicial Admission (2/19) File No.
4. b. The following conduct and statements by the individual, which I have been informed others have seen or heard:
by Witness name Complete address Telephone no.
by: Witness name Complete address Telephone no.
5. Persons interested in these proceedings are:
NAME RELATIONSHIP ADDRESS TELEPHONE NO.
6. The individual will not comply with an order for examination because
.
I REQUEST
7. The court order the individual to be examined at Facility
.
8. The court order a peace officer to take the individual into protective custody and transport him/her immediately to
Facility
for examination.
9. The individual be determined by the court to be a person meeting the criteria for judicial admission for treatment.
I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best ofmy information, knowledge, and belief.
Signature of attorney
Date
Name (type or print) Bar no.
Signature of petitioner
Address
Address
City, state, zip Telephone no.
City, state, zip Telephone no.
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PCM 225 (2/19) ORDER DISMISSING PETITION FOR DISCHARGE FROM JUDICIAL ADMISSION MCL 330.1532
Approved, SCAO JIS CODE: ODD
STATE OF MICHIGANPROBATE COURTCOUNTY OF
ORDER DISMISSING PETITION FORDISCHARGE FROM JUDICIAL ADMISSION
FILE NO.
In the matter of First, middle, and last name
1. Date of hearing:
Judge: Bar no.
THE COURT FINDS:
2. The individual named above was judicially admitted to a facility or hospital and has filed a petition for discharge.
3. Name
, a physician or licensed psychologist, has filed a report
concluding that the individual continues to meet the criteria for judicially ordered treatment.
4. IT IS ORDERED that the petition for discharge is dismissed.
Judge
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use only
(SEE SECOND PAGE)
STATE OF MICHIGANPROBATE COURTCOUNTY OF SIX-MONTH REVIEW REPORT
1. The individual presently resides at own home or with relatives a facility a hospital a private facility
and the address is
.
2. The individual was placed on authorized leave on
and continues on leave status.
3. By order of this court dated
the individual was placed in a
a. one-year assisted outpatient treatment program. b. one-year combined treatment program. c. one-year continuing hospitalization program. d. facility as a judicial admission.
4. I believe the individual has mental illness and
a. as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or unintentionallyseriouslyphysicallyinjureselforothers,andhasengagedinanactoractsormadesignificantthreats that are substantially supportive of this expectation.
b. as a result of that mental illness, the individual is unable to attend to those basic physical needs that must be attended to in order to avoid serious harm in the near future, and has demonstrated that inability by failing to attend to those basic physical needs.
c. the individual’s judgment is so impaired by that mental illness and whose lack of understanding of the need for treatment has caused him or her to demonstrate an unwillingness to voluntarily participate in or adhere to treatment that is necessary, on the basis of competent clinical opinion, to prevent a relapse or harmful deterioration of his or her condition, andpresentsasubstantialriskofsignificantphysicalormentalharmtotheindividualorothers.
5. I believe the individual has an intellectual disability and
a. can be reasonably expected in the near future to intentionally or unintentionally seriously physically injure self or another person and has overtly acted in a manner substantially supportive of that expectation. b.hasbeenarrestedandchargedwithanoffensethatwasaresultoftheintellectualdisability.
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Six-month Review Report (2/19) File No.
6. This conclusion is based on a. the following facts of which I have personal knowledge:
b. the following facts, which are based on reports by others whose names and addresses, if known, are:
7. The assisted outpatient treatment program (For judicial admission) outpatient program of care and treatment provided to the individual since the order, and the results are:
8. This treatment is is not adequate and appropriate to the individual's condition. The estimated time required
during the next six-month period, or proposed as assisted outpatient treatment, (For judicial admission) outpatient program of care and treatment,
and will be adequate and appropriate to the individual's condition: (Write"none"ifnomodificationsareexpected.)
9. The individual should be discharged from the treatment program. continues to be a person requiring treatment. continues to be a person meeting the criteria for judicial admission for treatment.
I declare under the penalties of perjury that this report has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date
Signature of physician or licensed psychologist
Name (type or print)
Title
Telephone no.
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PCM 227 (2/19) NOTICE TO ATTORNEY OF RETURN TO HOSPITAL/FACILITY FROM AUTHORIZED LEAVEMCR 5.743, MCR 5.746
Approved, SCAO JIS CODE: NRH
STATE OF MICHIGANPROBATE COURTCOUNTY OF
NOTICE TO ATTORNEY OFRETURN TO HOSPITAL/FACILITY FROM
AUTHORIZED LEAVE
FILE NO.
In the matter of
TO: ┌ ┐
└ ┘
1. The court has been notified that the individual named above was returned to
more than 10 days after being placed on authorized leave.
2. Court rules require that you consult with your client to determine whether the individual desires a hearing.
3. If you cannot attend to this immediately, please call the court so that substitute counsel might be appointed for your client.
Deputy probate register/clerk
I certify that on this date this notice was served on the attorney named above at the address shown above by
first-class mail. personal service.
Date
Signature
Please return a copy of this form with your response indicated below.
In accordance with court rule, I personally conferred with my client on Date
.
An appeal of the return has been filed. is filed. will probably not be filed.
Date
Attorney signature Bar no.
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Approved, SCAO
In the matter of First, middle, and last name
DOB:
Do not write below this line - For court use onlyUSE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
STATE OF MICHIGANPROBATE COURTCOUNTY OF
NOTIFICATION OF NONCOMPLIANCE REQUEST FOR MODIFIED ORDER
FILE NO.
PCM 230 (2/19) NOTIFICATION OF NONCOMPLIANCE AND REQUEST FOR MODIFIED ORDERMCL 330.1475(1), (3),
MCR 5.744(B)
PCS CODE: NCATCS CODE: NCAD
1. I, Name (type or print)
, make this notification as the
agency. mental health professional who is supervising the individual's assisted outpatient treatment program. individual.2. The individual who is the subject of this notification was ordered to undergo a program of assisted outpatient treatment or combined hospitalization and assisted outpatient treatment. a. The assisted outpatient treatment has not been or will not be sufficient to prevent the individual from inflicting harm or injuries to self or others. b. The individual is not complying with the order for assisted outpatient treatment or combined hospitalization and assisted outpatient treatment. c. I believe that my assisted outpatient treatment program is not appropriate.
3. The individual was in the hospital
days for mental health treatment. The individual needs immediate hospitalization.4. This conclusion is based upon a. my personal observation of the individual doing the following acts and saying the following things:
b. conduct and statements seen or heard by others and related to me:
5. A psychiatrist has ordered the individual to return to the hospital.
6. I request the court to modify its last order of assisted outpatient treatment combined hospitalization and assisted outpatient treatment to direct the individual to: a. undergo another assisted outpatient treatment program. b. undergo hospitalization or combined hospitalization and assisted outpatient treatment, with hospitalization not to exceed
days.
c. be transported to the hospital by a peace officer if the individual refuses to comply with the psychiatrist's order to return to the hospital.
Date
Signature
Title
Business Address
Agency
City, state, zip Telephone no.
State the conduct and statements and the name, address, and telephone number of each witness.
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use only
STATE OF MICHIGANPROBATE COURTCOUNTY OF
ORDER FOR REPORT AFTER NOTIFICATION
AND REPORT
FILE NO.
PCM 231 (2/19) ORDER FOR REPORT AFTER NOTIFICATION AND REPORT MCL 330.1475(2), MCL 330.1519
(SEE SECOND PAGE)
PCS CODE: ORNTCS CODE: ORN
1.Thecourthasreceivednotificationthat a.the90-dayorderforassistedoutpatienttreatmenthasnotbeensufficienttopreventtheindividualfrominflictingharm or injuries upon self or others. b.theone-yearorderforalternative/assistedoutpatienttreatmenthasnotbeenorwillnotbesufficienttopreventthe individualfrominflictingharmorinjuriesuponselforothers. c. theindividualnamedaboveisnotcomplyingwiththeorderofalternative/assistedoutpatienttreatment. d. itisbelievedthatthealternative/assistedoutpatienttreatmentprogramisnotappropriate.2. IT IS ORDERED that the
communitymentalhealthservicesprogram,reportasfollows.4. I have reviewedthenotificationtothecourttoreportasto spokenwiththepersonwhonotifiedthecourttoreportasto reviewed other available records to report as to spokenwithotherknowledgeablepersonstoreportasto a.thereasonforconcernabouttheadequacyoftheorderedcareortreatment:
b.thecontinuedsuitabilityofthecareortreatment:
c. theadequacy,fortheneedsoftheindividual,ofcareortreatmentavailableatahospitalorfacility:
REPORT ON ADEQUACY AND SUITABILITY OF ALTERNATIVE/ASSISTED OUTPATIENT TREATMENT
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Order for Report After Notification and Report (2/19) File No.
hospital, which I believehasanadequateandappropriatetreatmentprogramofthetypeandextenttomeettheindividual'sneedsand condition.
d. order the individual be judicially admitted to
facility.
e.orderapeaceofficertotaketheindividualintoprotectivecustodyandtransporttheindividualtothehospitalorfacility if the individual refuses to comply with the order of hospitalization or judicial admission.
ORDER FOLLOWING HEARING ON APPEALOF RETURN TO HOSPITAL/FACILITY
FROM AUTHORIZED LEAVE
FILE NO.
PCM 232 (2/19) ORDER FOLLOWING HEARING ON APPEAL OF RETURN TO HOSPITAL/FACILITY FROM AUTHORIZED LEAVE MCL 330.1408, MCL 330.1479, MCL 330.1537, MCR 5.743, MCR 5.743a, MCR 5.743b
THE COURT FINDS:3.Noticeofhearinghasbeengivenaccordingtolaw. was present in court. with4. The individual was not present for reasons stated on the record. The hearing was without a jury.
7. The individual does doesnot requiretreatment. a.Thereisclearandconvincingevidencethattheindividualrequirestreatmentatahospital. b.Thedirectorofthehospitalorfacilitylackedanadequatebasisforconcludingthattheindividualrequiresfurther treatment in the hospital or facility. c. The individual meets the criteria for judicial admission for treatment.
IT IS ORDERED: 8. The appeal is dismissed and the individual is returned to the hospital/facility. 9. The individual is discharged from the hospital or facility. 10. The individual is returned to authorized leave status. 11. The individual is discharged from the hospital and shall undergo an assisted outpatient treatment program under the
supervision of
for a period of
days, under the theorderofhospitalizationofupto60daysoracontinuingorder,inanyeventnottoexceedthedifferencebetween 90daysandthecombinedtimetheindividualhasbeenhospitalizedandonauthorizedleavestatusasfollows:
12. The individual is discharged from the hospital and shall undergo an assisted outpatient treatment program under the supervision of
13. The individual shall receive care and treatment through an alternative to admission to a facility for a period not to
exceed one year.
Date
Judge .
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PCM 233 (2/19) NOTICE OF RIGHT TO APPEAL RETURN AND APPEAL OF RETURN FROM AUTHORIZED LEAVEMCL 330.1408(3), MCL 330.1537(3), MCR 5.743, MCR 5.743a, MCR 5.743b
Approved, SCAO JIS CODE: NRA
STATE OF MICHIGANPROBATE COURTCOUNTY OF
NOTICE OF RIGHT TO APPEAL RETURNAND APPEAL OF RETURN
FROM AUTHORIZED LEAVE
FILE NO.
In the matter of First, middle, and last name
The above individual has been on authorized leave from a hospital or facility for more than 10 days. The individual was thenreturned to the hospital or facility involuntarily, as follows.
Date of last order Date of return Time of return Age of Individual Name of hospital/facility
You have a right to appeal your return to the hospital or facility and to have a hearing to determine the outcome of appeal. If you
wish to appeal, notify the
court within 7 days after receipt of this notice.
Complete the petition below and mail a copy to the court. In the case of a child who is less than 13 years of age, the appeal
must be made by the parent or guardian.
I certify that this notice was personally served on the above individual on Date
at Time
.
and a copy was mailed to
court on Date
.
Signature
NOTE TO COURT: MCR 5.743 and MCR 5.743b require form PCM 227 to be sent to the individual’s attorney.
I appeal my return to the hospital/facility and demand a hearing.
I request court-appointed legal counsel.
I declare under the penalties of perjury that this petition for appeal has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
individual parent
Date
Signature guardian
NOTICE OF RIGHT TO APPEAL
PROOF OF SERVICE
PETITION APPEALING RETURN TO HOSPITAL/FACILITY
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use only
STATE OF MICHIGANPROBATE COURTCOUNTY OF
REQUEST TO DEFERHEARING ON COMMITMENT
FILE NO.
PCM 235 (2/19) REQUEST TO DEFER HEARING ON COMMITMENT MCL 330.1455(6)
USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
PCS CODE: RTDTCS CODE: RDHC
PLEASE PRINT OR TYPE CLEARLY
1. I state that I have met with my legal counsel, a representative from the county community mental health program, and a member of the treatment team assigned to provide treatment. I agree to one of the following:
a. Inpatient hospital treatment not to exceed 60 days.
b. Outpatient treatment not to exceed 180 days.
c. Combined hospitalization and outpatient treatment up to 180 days with hospitalization not to exceed 60 days.
2. The treatment program will be as follows:
Hospitalization:
Outpatient treatment under the supervision of:
3. I request that the court hearing be deferred for not longer than 60 days from today if I have chosen to remain hospitalized, or 180 days from today if I have chosen outpatient treatment or a combination of hospitalization and outpatient treatment.
4. I understand that I may refuse this treatment at any time during this deferral period and demand a court hearing.
Date
Patient’s signature
Witness/Legal counsel Bar no.
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Approved, SCAO
In the matter of First, middle, and last name
Do not write below this line - For court use only USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
STATE OF MICHIGANPROBATE COURTCOUNTY OF DEMAND FOR HEARING
FILE NO.
PCM 236 (2/19) DEMAND FOR HEARING MCL 330.1455(6), (8)-(11)
PCS CODE: DFHTCS CODE: DFH
1. I am the individual, and I demand a court hearing.
2. I am the hospital director/designee, outpatient treatment provider/designee, and I demand a court hearing because the individual refuses to accept prescribed treatment. the individual orally demanded a hearing.
3. I am the executive director of the community mental health services program. The individual deferred the initial hearing and is participating in an outpatient treatment program in the community. The deferral period ends on
Date .
I believe s/he continues to require treatment, but s/he refuses to sign a voluntary treatment form, and I demand a court hearing. I believe s/he continues to require treatment, but s/he is found not suitable for voluntary treatment, and I demand a court hearing.
4. I am the director of the hospital where the individual has remained hospitalized since deferring the initial hearing on
Date . I believe the individual continues to require treatment and
will not agree to sign a formal voluntary admission, and I demand a court hearing. is not suitable for voluntary admission, and I demand a court hearing. 5.Theindividualrequireshospitalizationpendingthehearinganditisnecessarythatthecourtorderapeaceofficerto