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Supplemental Petition For Examination Or Hospitalization And Order Form. This is a Michigan form and can be use in Mental Health Statewide.
Tags: Supplemental Petition For Examination Or Hospitalization And Order, PCM 209a, Michigan Statewide, Mental Health
In the matter of First, middle, and last name � DOB: � 1. � Date of hearing: en-US � Judge: en-USBar no.en-USTHE COURT FINDS: 2. � A petition alleging the individual is a person requiring treatment and requesting hospitalization or a combined treatment order � 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. � 3. � The court has received information that a petition for assisted outpatient treatment has been filed, the petitioner has made � reasonable efforts to secure an examination, and the individual will not make himself/herself available for evaluation. � 4. � The individual requires immediate assessment because the individual presents a substantial risk of significant physical � � or mental harm to himself/herself in the near future or presents a substantial risk of significant physical harm to others in � the near future. � 5. � There does not appear to be probable cause to order the individual be taken into protective custody and transported to � � the designated prescreening unit or hospital. en-US en-USIT IS ORDERED: � 6. � The individual be examined by a � � psychiatrist. � � psychiatrist and a physician or licensed psychologist � � at en-USPrescreening unit or hospitalen-US . � 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 examinations 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 him/her to the designated � prescreening unit or hospital. If the order is not executed by en-US10 days from entry of orderen-US, the law enforcement � agency must report to the court the reason the order was not executed within the prescribed time period. � 7. � A peace officer shall take the individual into protective custody and transport him/her to the designated � prescreening unit or hospital for assessment for assisted outpatient treatment. If the order is not � executed by en-US10 days from entry of orderen-US, the law enforcement agency must report to the court the reason the order � � was not executed within the prescribed time period. � 8. � The request to take the individual into protective custody for transport is denied. en-USDate � Judge � 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 � en-USName � en-USLaw enforcement agency � 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