Free pcm218.p65 - Michigan

Approved, SCAO

JIS CODE: PCT, PCO

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. PETITION FOR SECOND OR CONTINUING TREATMENT ORDER

In the matter of 1. I,
Name (type or print)

, state that I am

the authorized representative of the agency or mental health professional supervising the individual's alternative treatment program. of .
Director or authorized representative of director Name of hospital

2. The individual is currently residing/hospitalized at

Address

.

3. The initial order for mental health treatment was made pursuant to a petition filed under MCL 330.1434. initial 4. The second order entered by this court for the individual expires on Date continuing 5. The individual continues to be a person requiring treatment and is in need of hospitalization for not more than 90 days. continuing hospitalization for a period of one year. combined hospitalization and alternative/assisted outpatient treatment for not more than one year. alternative/assisted outpatient treatment for not more than one year. 6. The individual is likely to refuse treatment on a voluntary basis when the order expires.

.

INSTRUCTIONS: In answering items 7 and 8, include a description of the observed or reported behavior of the individual, including, but not limited to, how behavior and conditions have changed since the last order and whether any stabilization or remission is contingent on continued medication or other treatment; avoid medical terms and conclusions other than diagnosis. 7. The basis for this allegation is that I believe the individual has a mental illness and as a result (check as many as are applicable) can reasonably be expected in the near future to intentionally or unintentionally seriously physically injure another person. can reasonably be expected in the near future to intentionally or unintentionally seriously physically injure self. is unable to attend to basic physical needs such as food, clothing or shelter that must be attended to in order to avoid serious harm. is unable to understand the need for treatment because of impaired judgment, and continued behavior can reasonably be expected, on the basis of competent clinical opinion, to result in significant physical harm to self or others. 8. This conclusion is based upon a. my personal observation of the person doing the following acts and saying the following things:

SEE SECOND PAGE
Do not write below this line - For court use only

PCM 218 (3/05)

PETITION FOR SECOND OR CONTINUING TREATMENT ORDER

MCL 330.1472a, MCL 330.1473

b. conduct and statements I have been informed that others have seen or heard:

by:
Name of witness Complete address Telephone no.

by:

Name of witness

Complete address

Telephone no.

9. The diagnoses of physical and mental condition are:

10. The treatment program(s) provided to the individual thus far, and the results, are:

11. The present treatment

is is not

adequate and appropriate to the individual's condition. The individual

is is not

motivated to participate in this treatment program. The estimate of time further treatment is required is . The following modifications are currently planned for the next period of treatment (write "none" if continuation of previous treatment program(s) is (are) the only course of treatment):

12.

The interested parties, their addresses, and their representatives are identical to those appearing on the initial petition except as follows: Attached is a clinical certificate executed by a psychiatrist. I REQUEST the court to order the individual to receive hospitalization for not more than 90 days. continuing hospitalization for not more than one year. combined hospitalization and alternative/assisted outpatient treatment for not more than one year. alternative/assisted outpatient treatment for not more than one year.

13. 14.

I declare 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 Address City, state, zip Telephone no.