Approved, SCAO
JIS CODE: OBH
STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION
OBJECTION TO HOSPITALIZATION OF A MINOR
FILE NO.
In the matter of 1. I object to the hospitalization of this minor and request the court to schedule a hearing on this objection.
Date Signature
, a minor
1. The person filing this objection is
Name
and is
the minor patient, who is 14 years of age or older. the minor's parent, guardian, or person in loco parentis. The request for hospitalization was made by the minor or a peace officer. a person designated by the court. was admitted is scheduled for admission
2. The minor is
years old and
to
upon the application of
Address City State Zip Telephone no.
who is the minor's
parent, guardian, person in loco parentis, i.e. other, i.e.
Date
3. The minor received a periodic review of his/her suitability for continued hospitalization on 4. The reason for this objection is:
.
Do not write below this line - For court use only
PCM 202 (9/07)
OBJECTION TO HOSPITALIZATION OF A MINOR
MCL 330.1498m