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Order For Report On Alternative Treatment And Report PCM 216 - Michigan
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Approved, SCAO JIS CODE: ORA, RAT STATE OF MICHIGAN PROBATE COURT COUNTY OF In the matter of FILE NO. ORDER FOR REPORT ON ALTERNATIVE TREATMENT AND REPORT , an alleged mentally ill person ORDER IT IS ORDERED that shall prepare a report assessing the current Name (type or print) availability and appropriateness of alternatives to hospitalization for the individual named above including alternatives available following an initial period of court-ordered hospitalization. The report shall be made to the court before the hearing on Date and time of hearing Petition for 60-day order, discharge, etc. for . Date Judge Bar no. REPORT ON EVALUATION OF HOSPITAL TREATMENT AND/OR ALTERNATIVE PROGRAMS 1. I, Name , as Profession, organization, and position , report as follows. 2. I have reviewed, as to their availability in or near the individual's home community, treatment resources alternative to hospitalization and report as follows: (If practical, give name of agency, program, etc.) a. Independent mental health professional: b. Community mental health day treatment, aftercare service, work activity, or other program: c. Substance abuse, rehabilitation service, or similar program of public or private agency: d. Other: (SEE SECOND PAGE) Do not write below this line - For court use only PCM 216 (9/10) ORDER FOR REPORT ON ALTERNATIVE TREATMENT AND REPORT MCL 330.1453a, MCR 5.741 American LegalNet, Inc. www.FormsWorkFlow.com 3. I have reviewed, as to their availability in or near the individual's home community, residential accommodations and report as follows: (If practical, give name of residence, location, etc.) a. Independent: Individual's own house, apartment, etc. b. Residence of relative or friend: c. Foster care home: d. Nursing home: e. Other: 4. The individual has 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. I recommend release. 6. I recommend a course of treatment of as follows: hospitalization hospitalization for an alternative program days, followed by an alternative program 7. My recommendation is based upon the following described interviews, observations, and information: 8. I believe the hospital to which admission is proposed appropriately and adequately because can cannot provide its prescribed treatment program . 9. I recommend the following agency or independent mental health professional to supervise the alternative treatment: Name Complete address The agency or professional has has not indicated capability and willingness to supervise the recommended program. 10. The individual currently has the following source(s) of funds to cover his or her care in the community: 11. The individual does not currently have sufficient sources of funds for community living. a. Application for supplemental funds has been made. They should be available b. Application for supplemental funds has not been made because Application will be made on and should be available about c. Pending receipt of supplemental funds, the following funds will be available: Direct relief. CMH emergency care funds. Other assistance: None. Reason: Date Signature American LegalNet, Inc. www.FormsWorkFlow.com . . .