Free pcm209a.p65 - Michigan

Approved, SCAO

JIS CODE: SPE

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

SUPPLEMENTAL PETITION FOR EXAMINATION / HOSPITALIZATION AND ORDER

FILE NO.

In the matter of PETITION I executed the attached Petition for Hospitalization (PCM 201) and I request 1. The court order the individual to be examined at the preadmission screening unit or hospital designated by the community mental health services program, by a psychiatrist. a psychiatrist and either a physician or licensed psychologist. 2. ,

a. the court order the individual be examined by a psychiatrist. Attached is one clinical certificate that was executed within the last 72 hours. b. the court find that a reasonable effort was made to secure an examination based on the following affidavit. No clinical certificate is attached. 3. If it appears to the court that the individual will not comply with the order, I request the court to order a peace officer to take the individual into protective custody and transport him/her to the site named in item 1. 4. the court immediately order the individual be hospitalized in order to prevent physical harm to self or others. I also request that the court order a peace officer to take the individual into protective custody and transport him/her to the site named in item 1.

I declare under the penalties of perjury that this supplemental 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

Use Note: Complete this affidavit only if paragraph 2.b. above has been checked.

AFFIDAVIT

5. No clinical certificate is attached because I have been unable, after reasonable effort, to secure an examination by a physician or licensed psychologist. The reasons I was not able to secure an examination are: (specify reasons)

Signature of petitioner

Subscribed and sworn to before me on
Date

, Signature:

County, Michigan.

My commission expires:
Date

Notary public, State of Michigan, County of (PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

MCL 330.1434, MCL 330.1435, MCL 330.1436 PCM 209a (9/06)

SUPPLEMENTAL PETITION FOR EXAMINATION / HOSPITALIZATION AND ORDER

ORDER THE COURT FINDS: 6. A petition alleging the individual is a person requiring treatment has been filed with the court and a. one clinical certificate accompanies the petition. The individual must be examined by a psychiatrist. b. no clinical certificate accompanies the petition. A reasonable effort was made to secure an examination. The individual must be examined by a psychiatrist and either a physician or a licensed psychologist. 7. The individual will not comply with an order of examination and it is necessary that a peace officer immediately take the individual into protective custody and transport him/her to the site named in item 1. 8. The individual needs immediate hospitalization to prevent physical harm to self or others. It is necessary that a peace officer immediately take the individual into protective custody and transport the individual to the site named in item 1. 9. There does not appear to be probable cause to take action on this petition. IT IS ORDERED: psychiatrist psychiatrist and a physician or licensed psychologist 10. The individual be examined by a at the site named in item 1. Upon completion of the examination(s), the executed clinical certificate(s) shall be filed with the court or a report that a clinical certificate is not warranted shall be made to the court. A peace officer shall take the individual into protective custody and transport him/her to the site named in item 1. 11. The individual shall be hospitalized. If the examinations and clinicial certificates are not completed within 24 hours after hospitalization, the individual shall be released. A peace officer shall take the individual into protective custody and transport him/her to the site named in item 1. 12. The petition is denied.

Date

Judge

Bar no.