JIS CODE: SAP Approved, SCAO STATE OF MICHIGAN PROBATE COURT COUNTY OF PETITION FOR SUBSTANCE ABUSE TREATMENT AND REHABILITATION SERVICES FILE NO. In the matter of , a minor 1. I, parent person in loco parentis of the minor who was , am the Name (type or print) born , is a resident of Date , and is presently found at County . 2. The persons interested in these proceedings are: NAME RELATIONSHIP ADDRESS TELEPHONE Minor Father Mother Program director Person in loco parentis 3. The minor is in need of substance abuse treatment and rehabilitation services. This conclusion is based upon the following facts: 4. Following a diagnostic evaluation, the minor was determined to be physiologically dependent, but the minor has not consented to substance abuse treatment and rehabilitation services. A copy of the evaluation is attached to this petition. (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only MCL 333.6123, MCL 333.6124 PC 611 (9/07) PETITION FOR SUBSTANCE ABUSE TREATMENT AND REHABILITATION SERVICES American LegalNet, Inc. www.FormsWorkflow.com 5. Psychotropic drugs are needed for the minor's treatment. This conclusion is based upon the following facts: Each drug proposed to be used is: 6. The least restrictive setting available for treatment of the minor is: 7. The treatment plan proposed for the minor is: 8. I am willing and able to provide or arrange for the management, care, or residence of the minor. I REQUEST THAT: 9. The court determine substance abuse treatment and rehabilitation services are necessary, including suitable placement for the minor. 10. The court order the use of psychotropic drugs in the treatment program. 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 Attorney signature Name (type or print) Signature Bar no. Address City, state, zip Name (type or print) Address Telephone no. City, state, zip Telephone no. American LegalNet, Inc. www.FormsWorkflow.com