Free pcm235.pmd - Michigan

Approved, SCAO

JIS CODE: RTD

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

FILE NO. REQUEST TO DEFER HEARING ON COMMITMENT

In the matter of PLEASE PRINT OR TYPE CLEARLY 1. I state that I have met with my legal counsel, a representative from the county community mental health program, and a member of the treatment team assigned to provide treatment. I agree to one of the following: a. Inpatient hospital treatment not to exceed 60 days. b. Treatment in a community alternative not to exceed 90 days. c. Combined hospitalization and alternative treatment up to 90 days with hospitalization not to exceed 60 days. 2. The treatment program will be as follows: Hospitalization: Alternative treatment under the supervision of:

3. I request that the court hearing be deferred for not longer than 60 days from today if I have chosen to remain hospitalized, or 90 days from today if I have chosen alternative treatment or a combination of hospitalization and alternative treatment. 4. I understand that I may refuse this treatment at any time during this deferral period and demand a court hearing.

Date

Patient's signature Witness/Legal counsel Bar no.

Do not write below this line - For court use only

PCM 235 (9/07)

REQUEST TO DEFER HEARING ON COMMITMENT

MCL 330.1455(5)