Free Order Appointing Commitment Review Panel - Michigan

Approved, SCAO

STATE OF MICHIGAN JUDICIAL CIRCUIT COURT COUNTY

CASE NO. ORDER APPOINTING COMMITMENT REVIEW PANEL Original Modified

In the matter of 1. Date of Hearing: Judge:
Bar no.

2. The court received a petition for treatment of infectious disease requesting that the individual be committed to .
Name of facility

3. The court received a motion from the above named individual requesting that Dr. a physician, be appointed to the commitment review panel previously appointed by the court. IT IS ORDERED: 4. The following physicians are appointed to the commitment review panel.

,

Name Name Name

Address Address Address

City City City

State State State

Zip Zip Zip

5. Dr. is discharged from the panel and the following physician is appointed to the commitment review panel as requested by the individual.

Name

Address

City

State

Zip

6. The commitment review panel shall a. review the need for commitment of the individual to a health facility. b. review the record of the proceeding. c. interview the individual, or document the reasons why the individual was not interviewed. d. recommend either commitment or an alternative or alternatives to commitment and document the reasons for the recommendation. e. make its recommendation to the court in writing before .
Date of hearing

Judge

Do not write below this line - For court use only

PC 107 (9/98)

ORDER APPOINTING COMMITMENT REVIEW PANEL

MCL 333.5205(8); MSA 14.15(5205)(8), MCR 5.782