Approved, SCAO JIS CODE: POT STATE OF MICHIGAN PROBATE COURT COUNTY OF In the matter of FILE NO. PETITION AND ORDER REGARDING TRANSPORT OF MINOR , a minor (date of birth PETITION ) I represent that: 1. The minor can be currently found at: 2. I have authority as State your relationship and I have requested voluntary hospitalization of the minor pursuant to MCL 330.1498d or MCL 330.1498h. The minor has been hospitalized pursuant to Chapter 4A of the Mental Health Code, and the director of hospital believes the minor should be returned to the hospital following an authorized unauthorized absence. 4. The following unsuccessful efforts by were made to transport the minor for evaluation or 3. Name hospitalization pursuant to Chapter 4A of the Mental Health Code: 5. I request that the court order the minor to be transported for evaluation and/or hospitalization pursuant to Chapter 4A of the Mental Health Code. I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature Name (type or print) Address City, state, zip Telephone no. ORDER THE COURT FINDS: 6. A request for hospitalization has been made pursuant to Chapter 4A of the Mental Health Code and the petitioner has been unable to transport the minor for an evaluation. 7. The minor was hospitalized pursuant to Chapter 4A of the Mental Health Code, is on an authorized unauthorized absence, and should be returned to the hospital. 8. Reasonable effort to transport the minor has been made. IT IS ORDERED: 9. The petition is denied. 10. That a peace officer take the minor into protective custody and transport him/her immediately to for an evaluation pursuant to Chapter 4A of the Mental Health Code, and if necessary thereafter, to hospital, and that the person requesting the transport order shall meet the minor at the evaluation site and remain with the minor for the duration of the evaluation. 11. That a peace officer take the minor into protective custody and transport him/her immediately to hospital. 12.That this order expires on Date . Judge Bar no. USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form. Do not write below this line - For court use only American LegalNet, Inc. www.FormsWorkFlow.com PCM 240 (9/14) PETITION AND ORDER REGARDING TRANSPORT OF MINOR MCL 330.1498d(1), MCL 330.1498h, MCL 330.1498k, MCL 300.1498t