Free pcm230.p65 - Michigan


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Date: February 15, 2008
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State: Michigan
Category: Court Forms - State
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http://courts.michigan.gov/scao/courtforms/mentalhealth/pcm230.pdf

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Approved, SCAO

JIS CODE: NCA

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. NOTIFICATION OF NONCOMPLIANCE REQUEST FOR MODIFIED ORDER

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

, make this notification as the

agency. mental health professional who is supervising the individual's alternative/assisted outpatient treatment program. individual. 2. The individual who is the subject of this notification was ordered to undergo a program of alternative/assisted outpatient treatment or combined hospitalization and alternative/assisted outpatient treatment. a. The alternative treatment has not been or will not be sufficient to prevent the individual from inflicting harm or injuries to self or others. b. The individual is not complying with the order for alternative/assisted outpatient treatment or combined hospitalization and alternative/assisted outpatient treatment. c. I believe that my alternative treatment program is not appropriate. 3. There remain days of hospitalization under the last order. The individual needs immediate hospitalization. 4. This conclusion is based upon a. my personal observation of the individual doing the following acts and saying the following things:

b. conduct and statements seen or heard by others and related to me:

state the conduct and statements and the name, address, and telephone number of each witness.

5. A psychiatrist has ordered the individual to return to the hospital. 6. I request the court to modify its last order of alternative treatment assisted outpatient treatment combined hospitalization and alternative/assisted outpatient treatment to direct the individual to: a. undergo another alternative/assisted outpatient treatment program. b. undergo hospitalization or combined hospitalization and alternative/assisted outpatient treatment, with hospitalization not to exceed days. c. to be transported to the hospital by a peace officer if the individual refuses to comply with the psychiatrist's order to return to the hospital.
Date Title Agency Signature Business address City, state, zip Telephone no.

Do not write below this line - For court use only

PCM 230 (9/06)

NOTIFICATION OF NONCOMPLIANCE AND REQUEST FOR MODIFIED ORDER

MCL 330.1475, MCR 5.744(B)