Free pcm237.p65 - Michigan

Approved, SCAO

JIS CODE: CHM

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. PETITION FOR CONTINUED HOSPITALIZATION OF MINOR

In the matter of 1. I, of 2. On
Date Name (type or print) Name of hospital

, a minor , am the director or authorized representative of the director . the hospital received a written notice of intent to terminate the hospitalization of the minor from: the guardian the person in loco parentis the minor who is 14 years of age or older and who

the parent

was admitted by his or her own request. 3. The minor is a resident of , Michigan, was born on ,

and has parents, guardian, or person in loco parentis as follows:
NAME RELATIONSHIP ADDRESS TELEPHONE

Father Mother Guardian Person in loco parentis 4. The minor is suitable for hospitalization because the minor requires treatment, is in need of hospitalization and is expected to benefit from hospitalization, and an appropriate, less restrictive alternative to hospitalization is not available. 5. The minor requires treatment because: of a substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life. of a severe or persistent emotional condition characterized by seriously impaired personality development, individual adjustment, social adjustment, or emotional growth, which is demonstrated in behavior symptomatic of that impairment. 6. This conclusion is based upon:

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PCM 237 (9/06)

PETITION FOR CONTINUED HOSPITALIZATION OF MINOR

MCL 330.1498o

7. The minor will benefit from hospitalization as follows:

8. I request that the minor be determined suitable for hospitalization and ordered to continue hospitalization for not more than 60 days.

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 of petitioner Title of petitioner

This petition is accompanied by one certificate executed by a child and adolescent psychiatrist and one certificate of a physician. licensed psychologist.