JIS CODE: SPE STATE OF MICHIGAN PROBATE COURT OAKLAND COUNTY CIRCUIT COURT ­ FAMILY DIVISION SUPPLEMENTAL PETITION FOR EXAMINATION / HOSPITALIZATION AND ORDER FILE NO. In the matter of PETITION I executed the attached Petition for Hospitalization (PCM 201) and I request: 1. The court order the individual to be examined at Common Ground-OACIS, 1200 N. Telegraph, Bldg. 32E, Pontiac, MI 48341 (248)456-1991 , the preadmission screening unit or hospital designated by the community mental health services program, by a psychiatrist. a psychiatrist and either a physician or licensed psychologist 2. a. The court order the individual be examined by a psychiatrist. Attached is one clinical certificate that was executed within the last 72 hours. b. The court find that a reasonable effort was made to secure an examination based on the affidavit below. No clinical certificate is attached. 3. If it appears to the court that the individual will not comply with the order the court order a peace officer to take the individual into protective custody and transport the individual to the site named in item 1. 4. The court immediately order the individual be hospitalized in order to prevent physical harm to self or others. I also request that the court order a peace officer to take the individual into protective custody and transport the individual to the site named in item 1. I declare under the penalties of perjury that this supplemental petition has been examined by me and that its contents are true to the best of my information, knowledge , and belief. Date Use Note: Complete this affidavit only if paragraph 2.b. above has been checked. Signature of petitioner AFFIDAVIT 5. No clinical certificate is attached because I have been unable, after reasonable effort, to secure an examination by a physician or licensed psychologist. The reasons I was not able to secure an examination are: (specify reasons) There is is not Court: a court action(s) pending between me and the subject of the petition. If so, please complete File # the following: Signature of petitioner Subscribed and sworn to before me on Date , Signature: County, Michigan. My commission expires: Date Notary public, State of Michigan, County of (SEE SECOND PAGE) Do not write below this line ­ For court use only FILED 20 Deputy Register of Probate MCL 330.1434, MCL 330.1435, MCL 330.1436 PEMH 1046 (1/14) SUPPLEMENTAL Modified from PCM 209a (9/09) PETITION FOR EXAMINATION / HOSPITALIZATION AND ORDER American LegalNet, Inc. www.FormsWorkFlow.com Case Name ORDER File No. THE COURT FINDS: 6. A petition alleging the individual is a person requiring treatment 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. 7. The individual will not comply with an order of examination and it is necessary that a peace officer immediately take the individual into protective custody and transport the individual to the site named in item 1. 8. The individual needs immediate hospitalization to prevent physical harm to self or others. It is necessary that a peace officer immediately take the individual into protective custody and transport the individual to the site named in item 1. 9. There does not appear to be probable cause to take action on this petition. IT IS ORDERED: 10. The individual be examined by a psychiatrist psychiatrist and a physician or licensed psychologist at the site named in item 1. 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 examination 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 the individual to the site named in item 1. 11. The petition is denied. Date Judge Bar no. American LegalNet, Inc. www.FormsWorkFlow.com