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Clinical Certificate PCM 208 - Michigan
| Clinical Certificate Form. This is a Michigan form and can be used in Mental Health Statewide . |
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Approved, SCAO OSM CODE: CCT STATE OF MICHIGAN FILE NO. PROBATE COURT CLINICAL CERTIFICATE COUNTY CIRCUIT COURT - FAMILY DIVISION In the matter of 1. TO THE EXAMINER: The following is a statement that must be read to the individual before proceeding with any questions. I am authorized by law to examine you for the purpose of advising the court if you have a mental condition which needs treatment and whether such treatment should take place in a hospital or in some other place. I am also here to determine if you should be hospitalized, or remain hospitalized, before a court hearing is held. I may be required to tell the court what I observe and what you tell me. I certify that on this date I read the above statement to the individual before asking any questions or conducting any examination.2. I further certify that I, , personally examined Print or type name of examiner Patient at Name and address where exam done on Date starting at Time m. and continuing for minutes.INSTRUCTIONS: In answering describe in detail the specific actions, statements, demeanor, and appearance of the individual, together with other information in reasonable detail, which underlie your conclusion. Indicate the source of any information notpersonally known or observed. If this certificate is to accompany a petition for discharge, also state why the individual continuesto be or is no longer a person requiring treatment or in need of hospitalization. 3. My determination is that the person is mentally ill (has a substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life). not mentally ill. 4. (if applicable) The person has convulsive disorder. alcoholism. other drug dependence. mental processes weakened by reason of advanced years. other (specify): been hospitalized involuntarily two or more times within the two year period immediately preceding the filing of the petition and has rejected aftercare programs and treatment. 5. My diagnosis is: 6. Facts serving as the basis for my determination are: SEE SECOND PAGE Do not write below this line - For court use only PCM 208 (9/00) CLINICAL CERTIFICATE MCL 330.1425; MSA 14.800(425), MCL 330.1435; MSA 14.800(435)<<<<<<<<<********>>>>>>>>>>>>> 26. (continued) 7. Explain in the space below the facts which lead you to believe that future conduct may result in (check applicable box) a. likelihood of injury to self. Facts: Therefore, I believe the person can reasonably be expected within the near future to intentionally or unintentionally seriously physically injure self. b. likelihood in injury to others. Facts: Therefore, I believe the person can reasonably be expected within the near future to intentionally or unintentionally seriously physically injure others. c. inability to attend to basic physical needs. Facts: Therefore, I believe that as a result of mental illness the examined person is unable to attend to those basic physical needs (such as food, clothing or shelter) that must be attended to in order to avoid serious harm in the near future. d. inability to understand need for treatment. Facts: Therefore, I believe that as a result of mental illness the examined person is unable to understand the need for treatment, and continued behavior can reasonably be expected to result in significant physical harm to self or others.8. I conclude the individual is is not a person requiring treatment.9. (optional) I recommend hospitalization alternative treatment as follows: I certify that I am a person authorized by law to certify as to the individuals mental condition. I am not related by blood or marriageeither to the person about whom this certificate is concerned or to any person who has filed, or whom I know to be planning to file,a petition in this proceeding. I declare that this certificate has been examined by me and that its contents are true to the best ofmy information, knowledge, and belief. Date Time of signing SignatureTitle (physician, psychiatrist, etc.) Print or type name and business telephone no.
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