Michigan > Statewide > Mental Health
Supplemental Petition For Examination Or Hospitalization And Order PCM 209a - Michigan
| Supplemental Petition For Examination Or Hospitalization And Order Form. This is a Michigan form and can be used in Mental Health Statewide . |
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Approved, SCAO OSM CODE: SPE STATE OF MICHIGAN SUPPLEMENTAL PETITION FOR FILE NO. PROBATE COURT EXAMINATION / HOSPITALIZATION COUNTY AND ORDER CIRCUIT COURT - FAMILY DIVISION In the matter of PETITION I executed the attached Petition for Hospitalization (PCM 201) and I request 1. The court order the individual to be examined at , the preadmission screening unit or hospital designated by the community mental health services program, by a psychiatrist. a psychiatrist and either a physician or licensed psychologist. 2. a. the court order the individual be examined by a psychiatrist. Attached is one clinical certificate that was executed within the last 72 hours. b. the court find that a reasonable effort was made to secure an examination based on the following affidavit. No clinical certificate is attached. 3. If it appears to the court that the individual will not comply with the order, I request the court to order a peace officer to take the individual into protective custody and transport him/her to the site named in item 1. 4. the court immediately order the individual be hospitalized in order to prevent physical harm to self or others. I also request that the court order a peace officer to take the individual into protective custody and transport him/her to the site named in item 1. I declare that this supplemental petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Date Signature of petitioner Use Note: Complete this affidavit only if AFFIDAVIT paragraph 2.b. above has been checked. 5. I have had personal contact within the last 24 hours with the subject of the attached petition for hospitalization and make this affidavit based upon my personal knowledge, information, and belief. 6. No clinical certificate is attached because I have been unable, after reasonable effort, to secure an examination by a physician or licensed psychologist. The reasons I was not able to secure an examination are: Signature of petitioner Subscribed and sworn to before me on Date , County, Michigan.My commission expires: Date Signature: (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only MCL 330.1434; MSA 14.800(434), MCL 330.1435; MSA 14.800(435), MCL 330.1436; MSA 14.800(436)PCM 209a (9/97) SUPPLEMENTAL PETITION FOR EXAMINATION / HOSPITALIZATION AND ORDER <<<<<<<<<********>>>>>>>>>>>>> 2 ORDER THE COURT FINDS: 7. A petition alleging the individual is a person requiring treatment has been filed with the court and a. one clinical certificate accompanies the petition. The individual must be examined by a psychiatrist. b. no clinical certificate accompanies the petition. A reasonable effort was made to secure an examination. The individual must be examined by a psychiatrist and either a physician or a licensed psychologist. 8. The individual will not comply with an order of examination and it is necessary that a peace officer immediately take the individual into protective custody and transport him/her to the site named in item 1. 9. The individual needs immediate hospitalization to prevent physical harm to self or others. It is necessary that a peace officer immediately take the individual into protective custody and transport the individual to the site named in item 1. IT IS ORDERED: 10. The individual be examined by a psychiatrist psychiatrist and a physician or licensed psychologist at the site named in item 1. Upon completion of the examination(s), the executed clinical certificate(s) shall be filed with the court or a report that a clinical certificate is not warranted shall be made to the court. A peace officer shall take the individual into protective custody and transport him/her to the site named in item 1. 11. The individual shall be hospitalized. If the examinations and clinicial certificates are not completed within 24 hours after hospitalization, the individual shall be released. A peace officer shall take the individual into protective custody and transport him/her to the site named in item 1. Date Judge Bar no.
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