Approved, SCAO
JIS CODE: NRA
STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION
NOTICE OF RIGHT TO APPEAL RETURN AND APPEAL OF RETURN FROM AUTHORIZED LEAVE
FILE NO.
In the matter of The above individual has been on authorized leave from a hospital or center for more than 10 days. The individual was then returned to the hospital or center involuntarily, as follows.
Date of last order Date of return Time of return Age of individual Name of hospital/center
NOTICE OF RIGHT TO APPEAL You have a right to appeal your return to the hospital or center and to have a hearing to determine the outcome of appeal. If you wish to appeal, notify the Court within 7 days after receipt of this notice.
Complete the petition below and mail a copy to the court. In the case of a child who is less than 13 years of age, the appeal must be made by the parent or guardian. PROOF OF SERVICE I certify that this notice was personally served on the above individual on
Date
at
Time
, .
and a copy was mailed to
Court on
Date
Signature
NOTE TO COURT: MCR 5.743 and MCR 5.743b require form PCM 227 to be sent to the individual's attorney.
PETITION APPEALING RETURN TO HOSPITAL I appeal my return to the hospital/center and demand a hearing. I request court-appointed legal counsel. I declare under the penalties of perjury that this petition for appeal has been examined by me and that its contents are true to the best of my information, knowledge, and belief. individual parent guardian
Date Signature
Do not write below this line - For court use only
MCL 330.1408(3), MCL 330.1537(3), MCR 5.743, MCR 5.743a, MCR 5.743b PCM 233 (9/08)
NOTICE OF RIGHT TO APPEAL RETURN AND APPEAL OF RETURN FROM AUTHORIZED LEAVE