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Petition For Assisted Outpatient Treatment Form. This is a Michigan form and can be use in Mental Health Statewide.
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Tags: Petition For Assisted Outpatient Treatment, PCM 242, Michigan Statewide, Mental Health
Approved, SCAO
JIS CODE: PAS
STATE OF MICHIGAN
PROBATE COURT
COUNTY
FILE NO.
PETITION FOR
ASSISTED OUTPATIENT TREATMENT
CIRCUIT COURT - FAMILY DIVISION
In the matter of
Court ORI
Date of birth
1. I,
Race
Sex
, an adult
Name (type or print)
petition because
specify whether a relative, neighbor, peace officer, etc.
I believe the individual named above needs treatment.
2. The individual was born
, has a permanent residence in
Date
County at
Street address
City
State
Zip
and can presently be found at
.
Address
3. I believe the individual has mental illness and as a result of this mental illness the individual's understanding of the need for
treatment is impaired to the point that he or she is unlikely to participate in treatment voluntarily.
4. The individual is currently noncompliant with treatment, recommended by
Name of mental health provider
,
Address of mental health provider
City
State
Telephone number
that has been determined to be necessary to prevent a relapse or harmful deterioration of the individual's condition.
5. The individual's noncompliance with this treatment has been a factor in his/her:
a. placement in
a psychiatric hospital
jail
prison
at least 2 times within the last 48 months. (Specify the
name[s] and location[s] of the hospital, jail, or prison and the date[s] of hospitalization or incarceration.)
b. committing one or more acts, attempts, or threats of serious violent behavior within the last 48 months. (Specify the
acts, attempts, or threats of serious violent behavior.)
6. The statements made above are based on
a. my personal observation of the person doing the following acts and saying the following things:
(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only
PCM 242 (9/08)
PETITION FOR ASSISTED OUTPATIENT TREATMENT
MCL 330.1401(1)(d), MCL 330.1433
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b. conduct and statements that others have seen or heard and have told me about:
by:
Witness name
Complete address
Telephone no.
Witness name
Complete address
Telephone no.
by:
7. The persons interested in these proceedings are
NAME
RELATIONSHIP
ADDRESS
TELEPHONE
Spouse
Guardian
8. The individual
is
is not
a veteran.
9. I request the court to determine the individual to be a person requiring assisted outpatient treatment.
I declare 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 of attorney
Name (type or print)
Bar no.
Address
City, state, zip
Signature of petitioner
Address
Telephone no.
City, state, zip
Home telephone no.
Work telephone no.
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