Approved, SCAO JIS CODE: DIP STATE OF MICHIGAN PROBATE COURT COUNTY CIRCUIT COURT - FAMILY DIVISION PETITION FOR DISCHARGE FROM CONTINUING TREATMENT OR JUDICIAL ADMISSION FILE NO. In the matter of 1. I, , state that I am Name (type or print) a patient/resident in . Name of hospital or center the executive director of the community mental health services program for the county of residence of the individual. under a one-year alternative or a one-year combined-treatment order under the supervision of . INSTRUCTIONS: The petitioner may, within 7 days (excluding Sundays and holidays) after a periodic report is received, petition the court for a discharge. In addition to this right, the petitioner may petition for discharge once within each 12-month period following the date of the original order for continuing involuntary mental health treatment or judicial admission. If the petitioner is filing a petition after a periodic review, complete item 2. If the petitioner is filing a petition for the additional hearing, complete item 3. If the petitioner desires a hearing for discharge at any other time, this can be done only upon leave of the court by completing item 4. 2. I object to the conclusion(s) in the periodic review report of Name of patient/resident dated and filed with this court. The individual named in that report is not a person requiring treatment and should be discharged. is not in need of hospitalization. is not in need of alternative treatment. does not meet the criteria for judicial admission stated in MCL 330.1531(3). 3. This petition is filed as of right during the 1st, 2nd, 3rd, etc. 12-month period since , Date the date of the original order of continuing involuntary mental health treatment or judicial admission. a. This petition is accompanied by a clinical certificate of a physician or licensed psychologist stating the reasons the individual is not a person requiring treatment, or by a report of a psychologist stating the resident is not an individual who meets the criteria for judicial admission. b. This petition is not accompanied by the required clinical certificate/report of a physician or licensed psychologist because the individual is indigent. the individual is unable to obtain the clinical certificate/report because (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only MCL 330.1484, MCL 330.1485, MCL 330.1531,MCL 330.1532 PCM 220 (9/08) PETITION FOR DISCHARGE FROM CONTINUING TREATMENT OR JUDICIAL ADMISSION American LegalNet, Inc. www.FormsWorkflow.com 4. Although the petitioner is not entitled as of right by statute to petition at this time, the petitioner believes that the individual should be discharged because the individual is no longer a person requiring treatment is not a person meeting the criteria for judicial admission because of the following reasons: 5. The interested parties, their addresses, and their representatives are identical to those appearing on the initial petition, except as follows: 6. I REQUEST the court to a. set a hearing and order a discharge. b. (if 3b is checked) appoint a physician/licensed psychologist to examine the individual and file a clinical certificate/report. c. (if 4 is checked) grant leave to file this petition. 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 of petitioner Name (type or print) Address City, state, zip Telephone no. American LegalNet, Inc. www.FormsWorkflow.com