Free pcm211.pmd - Michigan

Approved, SCAO

JIS CODE: NO/CSP

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. NOTICE OF HOSPITALIZATION AND CERTIFICATE OF SERVICE

In the matter of NOTICE TO THE PROBATE COURT: Attached is an application for hospitalization and two clinical certificates. You are notified that: 1. The individual named above was hospitalized on
Date

at
Time Date

. at
Time

2. The clinical certificate of the psychiatrist that is required for hospitalization was completed on

.

CERTIFICATE OF SERVICE ON PATIENT 3. I certify that on the dates and times indicated a copy of each of the following documents was given to the individual named above. a. Application/Petition
Date Time Time Time Time Signature Signature Signature Signature

b. Statement explaining individual's rights
Date

c. Clinical certificate of psychiatrist
Date

d. Clinical certificate of licensed psychologist/ physician/psychiatrist e. Notice of hearing

Date

Date

Time

Signature

CERTIFICATE OF SERVICE ON OTHERS 4. I certify that copies of the application/petition, two clinical certificates, statement explaining rights, and notice of hearing were by first-class mail served personally on on
Date and time Individual's guardian nearest relative

and

by first-class mail personally on
Date and time

on
Individual's attorney

5. I further certify that the individual was asked if s/he desired that other persons be served with copies of these documents, and the individual designated
Name(s)

. by mail. personally.
Date

a. Copies were served on them on __________________________ b. Service was not made because the person(s) could not be located.
Date Signature

Do not write below this line - For court use only

MCL 330.1430, MCL 330.1431, MCL 330.1448, MCL 330.1449 PCM 211 (9/07)

NOTICE OF HOSPITALIZATION AND CERTIFICATE OF SERVICE