Free pc664.pmd - Michigan

Approved, SCAO

JIS CODE: PDA

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY

FILE NO.

In the matter of 1. I,
Name

, an individual with a developmental disability , am interested in this matter and make this petition as guardian of

the individual. 2. The individual is presently residing at
City

Address

.
State Zip

3. It is necessary that I be authorized by this court to admit the individual a. temporarily for a period not to exceed 30 days to
Name of center

located at b. to
Name of center

to receive clinical services. , located at

for up to 10 days for a preadmission examination and subsequent administrative admission if suitable. c. to
Name of facility

, located at

.

4. A report and evaluation required by law and court rule is filed with this petition. 5. The following are all the interested persons in this proceeding, none of which are under legal disability except as noted: NAME AGE RELATIONSHIP ADDRESS

6. I REQUEST that I be authorized to execute the necessary applications for the administrative admission of the individual to
Name of facility

.

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.

Attorney signature Name (type or print) Address City, state, zip Telephone no. Bar no.

Date Petitioner signature Address City, state, zip Telephone no.

Do not write below this line - For court use only

MCL 330.1100b, MCL 330.1509, MCL 330.1510, MCL 330.1623, MCR 5.746 PC 664 (9/07)

PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY