Approved, SCAO JIS CODE: NRR STATE OF MICHIGAN PROBATE COURT COUNTY CIRCUIT COURT - FAMILY DIVISION NOTICE OF RIGHT TO OBJECT TO HOSPITALIZATION, OBJECTION AND DEMAND FOR HEARING FILE NO. In the matter of , a mentally ill person 1. On , after a hearing required by statute, the court found you to be a person requiring Date treatment and entered an order for a program of alternative treatment. 2. a. After being notified that the alternative program was insufficient, you did not comply with the alternative program, the court entered an order (form PCM 217a) modifying the above order, resulting in your return to the hospital and/or placement on a different alternative treatment program. A copy of the amended order (form PCM 217a) is attached. b. The court has been notified that you have been hospitalized by a psychiatrist's order pursuant to MCL 330.1474a. NOTICE OF RIGHT TO OBJECT TO: You are notified that you may object to the court's or psychiatrist's order returning you to the hospital by completing the objection below and returning it to the court not later than 7 days after receiving this notice. The court will schedule a hearing within 10 days after receiving your objection. PROOF OF SERVICE I certify that on at Date I personally served this notice on the individual named in the Time Notice of Right to Object. Date Signature OBJECTION TO HOSPITALIZATION AND DEMAND FOR HEARING I object to my return to the hospital and demand a hearing. I request court-appointed legal counsel. Date Signature Name (type or print) Do not write below this line - For court use only PCM 241 (9/08) NOTICE OF RIGHT TO OBJECT TO HOSPITALIZATION AND OBJECTION MCL 330.1475a, MCR 5.744 American LegalNet, Inc. www.FormsWorkflow.com