Approved, SCAO STATE OF MICHIGAN APPEAL OF COMMITMENT AND CASE NO. JUDICIAL CIRCUIT COURT ORDER TO RECONVENE COUNTY COMMITMENT REVIEW PANEL In the matter of CLAIM OF APPEAL 1. I was committed to and am presently in , Name of facility as ordered by the court on . Date 2. I claim an appeal of my commitment. I REQUEST that the court reconvene my commitment review panel for a recommendation as to whether my commitment should be terminated. I understand that the court will reconvene the commitment review panel as soon as possible, but not more than 14 days after I have filed this claim of appeal. Date Signature ORDER 1. Date of Hearing: Judge: Bar no.IT IS ORDERED: 2. The previously appointed commitment review panel consisting of , Name , and Name Name shall reconvene and report to the court in writing within 14 days of the date of this order. 3. The panel shall do the following: a. Review the appeal and any other information considered relevant by the commitment review panel. b. Interview the individual, or document the reasons why the individual was not interviewed. c. Recommend to the circuit court either termination or continuation of the commitment and document the reasons for the recommendation. Date Judge Do not write below this line - For court use only MCL 333.5205(10); MSA 14.15(5205(10), MCR 5.782PC 113 (6/98) APPEAL OF COMMITMENT AND ORDER TO RECONVENE COMMITMENT REVIEW PANEL