Approved, SCAO
JIS CODE: NO/CSP
STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION
FILE NO. NOTICE OF HOSPITALIZATION AND CERTIFICATE OF SERVICE
In the matter of NOTICE TO THE PROBATE COURT: Attached is an application for hospitalization and two clinical certificates. You are notified that: 1. The individual named above was hospitalized on
Date
at
Time Date
. at
Time
2. The clinical certificate of the psychiatrist that is required for hospitalization was completed on
.
CERTIFICATE OF SERVICE ON PATIENT 3. I certify that on the dates and times indicated a copy of each of the following documents was given to the individual named above. a. Application/Petition
Date Time Time Time Time Signature Signature Signature Signature
b. Statement explaining individual's rights
Date
c. Clinical certificate of psychiatrist
Date
d. Clinical certificate of licensed psychologist/ physician/psychiatrist e. Notice of hearing
Date
Date
Time
Signature
CERTIFICATE OF SERVICE ON OTHERS 4. I certify that copies of the application/petition, two clinical certificates, statement explaining rights, and notice of hearing were by first-class mail served personally on on
Date and time Individual's guardian nearest relative
and
by first-class mail personally on
Date and time
on
Individual's attorney
5. I further certify that the individual was asked if s/he desired that other persons be served with copies of these documents, and the individual designated
Name(s)
. by mail. personally.
Date
a. Copies were served on them on __________________________ b. Service was not made because the person(s) could not be located.
Date Signature
Do not write below this line - For court use only
MCL 330.1430, MCL 330.1431, MCL 330.1448, MCL 330.1449 PCM 211 (9/07)
NOTICE OF HOSPITALIZATION AND CERTIFICATE OF SERVICE