Michigan > Statewide > Substance Abuse Treatment
Petition For Substance Abuse Treatment And Rehabilitation Services PC 611 - Michigan
| Petition For Substance Abuse Treatment And Rehabilitation Services Form. This is a Michigan form and can be used in Substance Abuse Treatment Statewide . |
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Approved, SCAO OSM CODE: SAP STATE OF MICHIGAN FILE NO. PETITION FOR PROBATE COURT COUNTY OF SUBSTANCE ABUSE TREATMENT AND REHABILITATION SERVICES In the matter of , a minor parent 1. I, , am the person in loco parentis of the minor who was Name (type or print) born , is a resident of , and is presently found at Date County .2. The persons interested in these proceedings are: NAME RELATIONSHIP ADDRESS TELEPHONE Minor Father Mother Program director Person in loco parentis 3. The minor is in need of substance abuse treatment and rehabilitation services. This conclusion is based upon the following facts: 4. Following a diagnostic evaluation, the minor was determined to be physiologically dependent, but the minor has not consented to substance abuse treatment and rehabilitation services. A copy of the evaluation is attached to this petition. (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only MCL 333.6123; MSA 14.15(6123), MCL 333.6124; MSA 14.15(6124) PC 611 (3/00) PETITION FOR SUBSTANCE ABUSE TREATMENT AND REHABILITATION SERVICES <<<<<<<<<********>>>>>>>>>>>>> 25. Psychotropic drugs are needed for the minors treatment. This conclusion is based upon the following facts: Each drug proposed to be used is 6. The least restrictive setting available for treatment of the minor is 7. The treatment plan proposed for the minor is 8. I am willing and able to provide or arrange for the management, care, or residence of the minor. I REQUEST THAT: 9. The court determine substance abuse treatment and rehabilitation services are necessary and the suitable placement for the minor. 10. The court order the use of psychotropic drugs in the treatment program. I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, andbelief. Date Attorney signature Signature Name (type or print) Bar no. Name (type or print) Address Address City, state, zip Telephone no. City, state, zip Telephone no.
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