In the matter of First, middle, and last name en-USIT IS ORDEREDen-US that en-USName (type or print)en-US shall prepare a report assessing the currenten-USavailability and appropriateness of alternatives to hospitalization for the individual named above including alternatives availableen-USfollowing an initial period of court-ordered hospitalization.en-USThe report shall be made to the court before the hearing on en-USDate and time of hearingen-US for en-USPetition for 60-day order, discharge, etc.en-US . en-USDate � Judge � Bar no. 1. � I, en-USNameen-US , as en-USProfession, organization, and positionen-US , report as follows. 2. � I have reviewed, as to their availability in or near the individual222s home community, treatment resources alternative to � hospitalization and report as follows: en-US(If practical, give name of agency, program, etc.) � a. � Independent mental health professional: en-US � � en-US � b. � Community mental health day treatment, aftercare service, work activity, or other program: en-US � en-US � en-US � en-US � c. � Substance abuse, rehabilitation service, or similar program of public or private agency: en-US � en-US � d. � Other: en-US � en-US � en-US en-USORDER en-USREPORT ON EVALUATION OF HOSPITAL TREATMENT AND/OR ALTERNATIVE PROGRAMS American LegalNet, Inc. www.FormsWorkFlow.com File No. 3. � I have reviewed, as to their availability in or near the individual's home community, residential accommodations and report � as follows: en-US(If practical, give name of residence, location, etc.) � a. � Independent: en-USIndividual222s own house, apartment, etc. � b. � Residence of relative or friend: en-US � c. � Foster care home: en-US � en-US � d. � Nursing home: en-US � e. � Other: en-US � en-US � 4. � I recommend release. � � 5. � I recommend a course of treatment of � � hospitalization � � hospitalization for en-US en-US days, followed by � assisted outpatient treatment as follows: � en-US � en-US 6. � My recommendation is based upon the following described interviews, observations, and information: � en-US � en-US � en-US � en-US 7. � I believe the hospital to which admission is proposed � � can � � cannot � provide its prescribed treatment program � � appropriately and adequately because en-US � en-US 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: � en-US � � � � � � � � � � � � � � a. � Application for supplemental funds has been made. They should be available en-US en-US . � � b. � Application for supplemental funds has not been made because en-US en-US . � Application will be made on en-US en-US and should be available about en-US en-US . � c. � Pending receipt of supplemental funds, the following funds will be available: � � Direct relief. � � MDHHS/CMH emergency care funds. � � Other assistance: en-US � � None. Reason: en-US en-USDate � en-USSignature American LegalNet, Inc. www.FormsWorkFlow.com