Approved, SCAO STATE OF MICHIGAN PROBATE COURT COUNTY CIRCUIT COURT - FAMILY DIVISION JIS CODE: SPA SUPPLEMENTAL PETITION TO APPLICATION FOR HOSPITALIZATION AND ORDER FOR EXAMINATION FILE NO. In the matter of PETITION 1. I executed the attached Application for Hospitalization (PCM 201). I have been unable to have the individual examined by a physician or licensed psychologist although I have made the following efforts: 2. I request the court to order a. the individual to be examined at the preadmission screening unit designated by the community mental health services program. b. a peace officer to take the individual into protective custody and transport him/her to the preadmission screening unit named above for the examination. 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 Attorney name (type or print) Bar no. Address Name (type or print) Address City, state, zip Telephone no. City, state, zip ORDER THE COURT FINDS: 3. The application is reasonable and in full compliance with section 424 of the Mental Health Code. 4. A reasonable effort was made to secure an examination. 5. It is necessary that a peace officer take the individual into protective custody and immediately transport him or her to the designated preadmission screening unit for the examination. IT IS ORDERED: 6. The individual be examined at the designated preadmission screening unit. 7. A peace officer shall take the individual into protective custody and immediately transport him or her to the designated preadmission screening unit provided that the individual is presented for examination by Date which is within 10 days of the date of execution of the application. Date Judge , Bar no. Do not write below this line - For court use only MCL 330.1428, MCL 330.1429 PCM 209 (9/06) SUPPLEMENTAL PETITION TO APPLICATION FOR HOSPITALIZATION AND ORDER FOR EXAMINATION American LegalNet, Inc. www.FormsWorkflow.com