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Six Month Review Report PCM 226 - Michigan
| Six Month Review Report Form. This is a Michigan form and can be used in Mental Health Statewide . |
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Approved, SCAO OSM CODE: SRR STATE OF MICHIGAN FILE NO. PROBATE COURT SIX MONTH REVIEW REPORT COUNTY CIRCUIT COURT - FAMILY DIVISION In the matter of 1. The individual presently resides at own home or with relatives a center a hospital a private facility and the address is 2. The individual was placed on authorized leave on and continues on leave status.3. By order of this court dated the individual was placed in a a. one year alternative treatment program. b. one year combined treatment program. c. one year continuing hospitalization program. d. center or private facility as a judicial admission. 4. I believe the individual has mental illness and a. can reasonably be expected within the near future to intentionally or unintentionally seriously physically injure self or another person, and the individual has engaged in an act or acts or made significant threats that are substantially supportive of the expectation. b. is unable to attend to those of his/her basic physical needs such as food, clothing, or shelter that must be attended to in order for the individual to avoid serious harm in the near future, and the individual has demonstrated that inability by failing to attend to those basic physical needs. c. his/her judgment is so impaired that the individual is unable to understand his/her need for treatment, and the individuals continued behavior as the result of this mental illness can reasonably be expected to result in significant physical harm to self or others. 5. I believe the individual has mental retardation and can be reasonably expected in the near future to intentionally or unintentionally seriously physically injure self or another person and has overtly acted in a manner substantially supportive of that expectation. 6. My conclusion is based on the following facts of which I have personal knowledge: (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only MCL 330.1401; MSA 14.800(401), MCL 330.1482; MSA 14.800(482),PCM 226 (9/97) SIX MONTH REVIEW REPORT MCL 330.1515; MSA 14.800(515), MCL 330.1531; MSA 14.800(531)<<<<<<<<<********>>>>>>>>>>>>> 27. My conclusion is based on the following facts which are based on reports by others whose names and addresses, if known, are: 8. The alternative treatment program provided to the individual since the order, and the results are: is 9. This treatment is not adequate and appropriate to the individuals condition, the estimate of time required for further days treatment is months and the following modifications in treatment are currently planned during the next six month period or proposed as alternative treatment, and will be adequate and appropriate to the individuals condition: (write "none" if continuation of previous treatment program(s) is(are) the only course of treatment currently envisaged)10. The individual a. continues to be a person requiring involuntary mental health treatment. b. continues to be a person meeting the criteria for judicial admission. c. should be discharged from the treatment program. I declare that this report has been examined by me and that its contents are true to the best of my information, knowledge, and belief.Date Signature of person making report Name (type or print) Title Telephone no.
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