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Petition Or Application For Hospitalization Form. This is a Michigan form and can be use in Mental Health Statewide.
Tags: Petition Or Application For Hospitalization, PCM 201, Michigan Statewide, Mental Health
In the matter of First, middle, and last name Last four digits of SSN Court ORIDate of birthPlace of birthRaceSex STATE OF MICHIGANPROBATE COURTCOUNTY OF PETITION FOR MENTAL HEALTH TREATMENT AMENDEDFILE NO. 1. I, en-USName (type or print)en-US, an adult en-USen-US petition because I believe the individual named above needs treatment. 2. The individual was born en-USDateen-US , has a permanent residence in County at Street address þ City State ZIP and can presently be found at en-USFacility name or other addressen-US . þ This petition is for a person who was found not guilty by reason of insanity in this county (NGRI). 3. I believe the individual has mental illness and a. as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or that are substantially supportive of this expectation. b. as a result of that mental illness, the individual is unable to attend to those basic physical needs that must be attended to in order to avoid serious harm in the near future, and has demonstrated that inability by failing to attend to those basic physical needs. c. the individual's judgment is so impaired by that mental illness, and whose lack of understanding of the need for treatment has caused him or her to demonstrate an unwillingness to voluntarily participate in or adhere to treatment that is necessary, on the basis of competent clinical opinion, to prevent a relapse or harmful deterioration of his or her condition, 4. The conclusions stated above are based on a.my personal observation of the person doing the following acts and saying the following things: b.the following conduct and statements that others have seen or heard and have told me about: by: Witness name þ Complete address þ þ Telephone no. American LegalNet, Inc. www.FormsWorkFlow.com File No. 5. The persons interested in these proceedings are: en-USNAMEen-USRELATIONSHIPen-USADDRESSen-USTELEPHONEen-USSpouseen-USGuardian*en-US*(Specify the county where the guardianship was established and the case number.) 6. þ The individual þ is þ en-US is not a veteran. 7. Attached is a en-US en-US en-US en-US8.en-US(For hospitalization and combined treatment only.) en-USAn examination could not be secured because en-USa. the individual be examined at en-US en-US, the preadmission screening unit or hospital designated by the community mental health services program. en-US en-US. a. order appropriate mental health treatment including hospitalization or a combination of hospitalization and assisted outpatient treatment. b. order that the individual participate in assisted outpatient treatment without hospitalization. en-USI declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of en-USmy information, knowledge, and belief. en-USSignature of attorney en-USDate Name (type or print) þ Bar no. en-USSignature of petitioner en-USAddress en-USAddress þ City, state, zip þ Telephone no. City, state, zip þ Home telephone no. þ Work telephone no. þ þ en-USFOR en-USHOSPITAL en-USUSE ONLYen-USThis petition for mental health treatment was received by the hospital on en-USDateen-USat en-USTimeen-US . en-USSignature of hospital representative American LegalNet, Inc. www.FormsWorkFlow.com