Free pcm215a.pmd - Michigan

Approved, SCAO

JIS CODE: CJA

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. CERTIFICATION AND REPORT ON PETITION FOR JUDICIAL ADMISSION

In the matter of CERTIFICATION OF EXAMINERS On
Date

, I examined the individual and report that: does does not does meet the criteria for judicial admission to a center. does not have mental retardation.

1. The individual

2. My diagnosis is that the individual

3. The individual can cannot be reasonably expected within the near future to intentionally or unintentionally seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation. I base my conclusion on the following facts:

4. The individual requires immediate admission to a center in order to prevent physical harm to self and others pending hearing.
Date Signature Name and title

On
Date

, I examined the individual and report that: does does not does meet the criteria for judicial admission to a center. does not have mental retardation.

1. The individual

2. My diagnosis is that the individual

3. The individual can cannot be reasonably expected within the near future to intentionally or unintentionally seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation. I base my conclusion on the following facts:

4. The individual requires immediate admission to a center in order to prevent physical harm to self and others pending hearing.
Date Signature Name and title

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PCM 215a (9/07)

CERTIFICATION AND REPORT ON PETITION FOR JUDICIAL ADMISSION

MCL 330.1516, MCR 5.741

REPORT ON PETITION FOR JUDICIAL ADMISSION 1. I,
Name

, as
Profession, organization, and title

,

have met with and evaluated the individual and report that his/her mental, physical, social, and educational condition is:

2. The following is a list of available forms of care and treatment that may serve as an alternative to admission to a center. a. Residential placement: Availability (specify): b. Day activity programs:

Availability (specify): c. Outpatient treatment:

Availability (specify): d. Custody of friend or relative: Availability (specify): e. Home care or homemaker services: Availability (specify): f. Inpatient treatment at private psychiatric hospital:
Name of hospital

Availability (specify): g. Other: Availability (specify): 3. I recommend the most appropriate living arrangement for the individual in terms of type and location and the availability of support services to be .

I declare under the penalties of perjury that this report has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Date Signature Address City, state, zip Telephone no.