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JIS CODE: PAS

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. PETITION FOR ASSISTED OUTPATIENT TREATMENT

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

.

3. I believe the individual has mental illness and as a result of this mental illness the individual's understanding of the need for treatment is impaired to the point that he or she is unlikely to participate in treatment voluntarily. 4. The individual is currently noncompliant with treatment, recommended by
Name of mental health provider

,
Address of mental health provider City State Telephone number

that has been determined to be necessary to prevent a relapse or harmful deterioration of the individual's condition. 5. The individual's noncompliance with this treatment has been a factor in his/her: a. placement in a psychiatric hospital jail prison at least 2 times within the last 48 months. (Specify the
name[s] and location[s] of the hospital, jail, or prison and the date[s] of hospitalization or incarceration.)

b. committing one or more acts, attempts, or threats of serious violent behavior within the last 48 months. (Specify the
acts, attempts, or threats of serious violent behavior.)

6. The statements made above are based on a. my personal observation of the person doing the following acts and saying the following things:

(PLEASE SEE OTHER SIDE)
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PCM 242 (9/08)

PETITION FOR ASSISTED OUTPATIENT TREATMENT

MCL 330.1401(1)(d), MCL 330.1433

b. 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.

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

Spouse Guardian

8. The individual

is

is not

a veteran.

9. I request the court to determine the individual to be a person requiring assisted outpatient treatment. 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.

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.