Free pcm216.pmd - Michigan

Approved, SCAO

JIS CODE: ORA, RAT

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. ORDER FOR REPORT ON ALTERNATIVE TREATMENT AND REPORT

In the matter of ORDER IT IS ORDERED that
Name (type or print)

, an alleged mentally ill person

shall prepare a report assessing the current

availability and appropriateness for the individual named above of alternatives to hospitalization including alternatives available following an initial period of court-ordered hospitalization. The report shall be made to the court by
Date Petition for 60-day order, discharge, etc.

, the date of a hearing on .

Date

Judge

Bar no.

REPORT ON EVALUATION OF HOSPITAL TREATMENT AND/OR ALTERNATIVE PROGRAMS 1. I,
Name

, as
Profession, organization, and position

, report as follows.

2. I have reviewed, as to their availability in or near the individual's home community, treatment resources alternative to hospitalization and report as follows: (if practical, give name of agency, program, etc.) a. Independent mental health professional:

b. Community mental health day treatment, aftercare service, work activity, or other program:

c. Substance abuse, rehabilitation service, or similar program of public or private agency:

d. Other:

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

PCM 216 (9/07)

ORDER FOR REPORT ON ALTERNATIVE TREATMENT AND REPORT

MCL 330.1453a, MCR 5.741

3. I have reviewed, as to their availability in or near the individual's home community, residential accommodations and report as follows: (if practical, give name of residence, location, etc.) a. Independent:
Individual's own house, apartment, etc.

b. Residence of relative or friend: c. Foster care home:

d. Nursing home: e. Other:

4. The individual has been hospitalized involuntarily two or more times within the two-year period immediately preceding the filing of the petition and has rejected aftercare programs and treatment. 5. I recommend release. 6. I recommend a course of treatment of as follows: hospitalization hospitalization for an alternative program days, followed by an alternative program

7. My recommendation is based upon the following described interviews, observations, and information:

8. I believe the hospital to which admission is proposed appropriately and adequately because:

can

cannot

provide its prescribed treatment program

9. I recommend the following agency or independent mental health professional to supervise the alternative treatment:
Name Complete address

The agency or professional has has not indicated capability and willingness to supervise the recommended program. 10. The individual currently has the following source(s) of funds to cover his or her care in the community:

11. The individual does not currently have sufficient sources of funds for community living. a. Application for supplemental funds has been made. They should be available b. Application for supplemental funds has not been made because Application will be made on and should be available about c. Pending receipt of supplemental funds, the following funds will be available: Direct relief. CMH emergency care funds. Other assistance: None. Reason:
Date Signature

. . .