Free pcm240.pmd - Michigan

Approved, SCAO

JIS CODE: POT

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. PETITION AND ORDER TO TRANSPORT MINOR

In the matter of PETITION I represent that: 1. I have authority as
State your relationship

, a minor

and I have requested voluntary hospitalization of the minor who can be

currently found at _________________________________________________________. The director of believes the minor should be returned to the hospital following an 2. The following unsuccessful efforts by
Name

authorized

hospital unauthorized absence. were made to transport the

minor for evaluation or hospitalization: 3. I request that the court order the minor to be transported for evaluation and/or hospitalization. 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 Signature Name (type or print) Address City, state, zip Telephone no.

ORDER THE COURT FINDS: 4. A request for hospitalization has been made and the petitioner has been unable to transport the minor for an evaluation. 5. The minor was hospitalized, is on an authorized unauthorized absence, and should be returned to the hospital. 6. Reasonable effort to transport the minor has been made. IT IS ORDERED: 7. That a peace officer take the minor into protective custody and transport him/her immediately to for an evaluation, and if necessary thereafter, to hospital, and that the person requesting the transport order shall meet the minor at the evaluation site and remain with the minor for the duration of the evaluation. 8. That a peace officer take the minor into protective custody and transport him/her immediately to hospital. 9. That this order expires on
Date

.
Judge Bar no.

Do not write below this line - For court use only

PCM 240 (9/07)

PETITION AND ORDER TO TRANSPORT MINOR

MCL 330.1498d(1), MCL 330.1498h, MCL 330.1498k, MCL 300.1498t