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Petition For Assisted Outpatient Treatment PCM 242 - Michigan
| Petition For Assisted Outpatient Treatment Form. This is a Michigan form and can be used in Mental Health Statewide . |
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Approved, SCAO JIS CODE: PAS STATE OF MICHIGAN PROBATE COURT COUNTY CIRCUIT COURT - FAMILY DIVISION FILE NO. PETITION FOR ASSISTED OUTPATIENT TREATMENT In the matter of Court ORI Date of birth Place of birth Race Sex 1. I, Name (type or print) , an adult Specify whether a relative, neighbor, peace officer, etc. , petition because I believe the individual named above needs treatment. 2. The individual was born Date , has a permanent residence in , City Address State Zip County at Street address and can presently be found at . 3. I believe the individual has mental illness and as a result of this mental illness the individual's understanding of the need for treatment is impaired to the point that the individual is unlikely to participate in treatment voluntarily. 4. The individual is currently noncompliant with treatment, recommended by Name of mental health provider , Address of mental health provider City State Telephone no. which has been determined to be necessary to prevent relapse or harmful deterioration of the individual's condition. 5. The individual's noncompliance with this treatment has been a factor in the individual's a. placement in a psychiatric hospital jail prison at least two times within the last 48 months. (Specify the name[s] and location[s] of the hospital, jail, or prison and the date[s] of hospitalization or incarceration.) b. committing one or more acts, attempts, or threats of serious violent behavior within the last 48 months. (Specify the acts, attempts, or threats of serious violent behavior.) 6. The above statements are based on a. my personal observation of the person doing the following acts and saying the following things: (SEE SECOND PAGE) Do not write below this line - For court use only PCM 242 (11/11) PETITION FOR ASSISTED OUTPATIENT TREATMENT MCL 330.1401(1)(d), MCL 330.1433 American LegalNet, Inc. www.FormsWorkFlow.com b. conduct and statements that others have seen or heard and have told me about. by Witness name Complete address Telephone no. by Witness name Complete address Telephone no. 7. The persons interested in these proceedings are: NAME RELATIONSHIP ADDRESS TELEPHONE Spouse Guardian 8. The individual is is not a veteran. 9. I request that the court determine the individual to be a person who requires assisted outpatient treatment. I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Signature of attorney Name (type or print) Address City, state, zip Telephone no. Bar no. Date Signature of petitioner Address City, state, zip Home telephone no. Work telephone no. American LegalNet, Inc. www.FormsWorkFlow.com
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