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 American LegalNet, Inc. www.FormsWorkflow.com 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. American LegalNet, Inc. www.FormsWorkflow.com