In the matter of First, middle, and last name þ DOB: þ 1. þ Date of hearing: en-US þ Judge: en-USBar no.en-USTHE COURT FINDS: 2. þ A petition alleging the individual is a person requiring treatment and requesting hospitalization or a combined treatment order þ has been filed with the court, and þ þ a. þ one clinical certificate accompanies the petition. The individual must be examined by a psychiatrist. þ þ b. þ no clinical certificate accompanies the petition. A reasonable effort was made to secure an examination. The individual þ must be examined by a psychiatrist and either a physician or a licensed psychologist. þ 3. þ The court has received information that a petition for assisted outpatient treatment has been filed, the petitioner has made þ reasonable efforts to secure an examination, and the individual will not make himself/herself available for evaluation. þ 4. þ The individual requires immediate assessment because the individual presents a substantial risk of significant physical þ þ or mental harm to himself/herself in the near future or presents a substantial risk of significant physical harm to others in þ the near future. þ 5. þ There does not appear to be probable cause to order the individual be taken into protective custody and transported to þ þ the designated prescreening unit or hospital. en-US en-USIT IS ORDERED: þ 6. þ The individual be examined by a þ þ psychiatrist. þ þ psychiatrist and a physician or licensed psychologist þ þ at en-USPrescreening unit or hospitalen-US . þ Upon completion of the examination(s), the executed clinical certificate(s) shall be filed with the court or a report that a þ þ clinical certificate is not warranted shall be made to the court. þ þ The individual shall be hospitalized. If the examinations and clinical certificates are not completed within 24 hours þ þ after hospitalization, the individual shall be released. þ þ A peace officer shall take the individual into protective custody and transport him/her to the designated þ prescreening unit or hospital. If the order is not executed by en-US10 days from entry of orderen-US, the law enforcement þ agency must report to the court the reason the order was not executed within the prescribed time period. þ 7. þ A peace officer shall take the individual into protective custody and transport him/her to the designated þ prescreening unit or hospital for assessment for assisted outpatient treatment. If the order is not þ executed by en-US10 days from entry of orderen-US, the law enforcement agency must report to the court the reason the order þ þ was not executed within the prescribed time period. þ 8. þ The request to take the individual into protective custody for transport is denied. en-USDate þ Judge þ Bar no. American LegalNet, Inc. www.FormsWorkFlow.com File No. en-USThe Order for Examination/Transport issued on en-USDateen-US has not been executed. The reason the order wasen-USnot executed within 10 days after entry is: en-US en-US en-US en-USDate þ en-USName þ en-USLaw enforcement agency þ en-USTelephone no.en-USTO THE LAW ENFORCEMENT AGENCY: en-USUnder MCL 330.1436(2), this report must be filed with the court that issued the en-USOrder for Examination/Transport if the order is not executed within 10 days after entry of the order.en-USREPORT OF NON-EXECUTION American LegalNet, Inc. www.FormsWorkFlow.com