Free pcm201.pmd - Michigan

Approved, SCAO

JIS CODE: AFH/PFH

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. PETITION/APPLICATION FOR HOSPITALIZATION XXX-XXLast four digits of SSN

In the matter of
Court ORI Date of birth Race

Sex

1. I,
Name (type or print)

, an adult
specify whether a relative, neighbor, peace officer, etc.

petition because

I believe the individual named above needs treatment. 2. The individual was born
Date

, has a permanent residence in
City Address State Zip

County at
Street address

and can presently be found at This petition is for a person who was found not guilty by reason of insanity in this county. 3. I believe the individual has mental illness and a. as a result of this mental illness, the individual can be reasonably expected within the near future to intentionally or unintentionally seriously physically injure self or others, and has engaged in an act or acts or made significant threats that are substantially supportive of this expectation.

.

b. the individual is unable to attend to those basic physical needs that must be attended to in order to avoid serious harm in the near future, and has demonstrated that inability by failing to attend to those basic physical needs. c. the individual's judgment is so impaired s/he is unable to understand the need for treatment. Continued behavior as the result of this mental illness can be reasonably expected, on the basis of competent clinical opinion, to result in significant physical harm to self or others. (If this is the only item checked, you must file this petition with the court before the person can be hospitalized.) 4. The conclusions stated above are based on a. my personal observation of the person doing the following acts and saying the following things:

(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

PCM 201 (9/08)

PETITION / APPLICATION FOR HOSPITALIZATION

MCL 330.1424, MCL 330.1434, MCL 330.1438, MCL 330.2050

b. the following conduct and statements that others have seen or heard and have told me about:

by:
Witness name Complete address Telephone no.

by:
Witness name Complete address Telephone no.

5. The persons interested in these proceedings are:
NAME RELATIONSHIP ADDRESS TELEPHONE

Spouse Guardian*

*(Specify the county where the guardianship was established and the case number.)

6. The individual

is

is not

a veteran.

7. I request the court to determine the individual to be a person requiring treatment and that s/he be hospitalized until the hearing. I declare under the penalties of perjury that this petition/application has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
Signature of attorney Name (type or print) Address City, state, zip Telephone no. Bar no. Date Signature of petitioner Address City, state, zip Home telephone no. Work telephone no.

Attached is a

clinical certificate by physician or licensed psychologist taken within the last 72 hours. clinical certificate by psychiatrist taken within the last 72 hours. petition/affidavit for examination (PCM 209 or PCM 209a) because examination could not be secured.

This Application for Hospitalization was filed with the hospital on
FOR HOSPITAL USE ONLY Signature of hospital representative

at

m.