Certification And Report On Petition For Judicial Admission {PCM 215a} | Pdf Fpdf Doc Docx | Michigan

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Certification And Report On Petition For Judicial Admission {PCM 215a} | Pdf Fpdf Doc Docx | Michigan

Certification And Report On Petition For Judicial Admission {PCM 215a}

This is a Michigan form that can be used for Mental Health within Statewide.

Alternate TextLast updated: 8/16/2006

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Approved, SCAO OSM CODE: CJA STATE OF MICHIGAN FILE NO. PROBATE COURT CERTIFICATION AND REPORT ON COUNTY PETITION FOR JUDICIAL ADMISSION CIRCUIT COURT - FAMILY DIVISION In the matter of CERTIFICATION OF EXAMINERS On I examined the individual and report that: Date 1. The individual does does not meet the criteria for judicial admission to a center. 2. My diagnosis is that the individual does does not have mental retardation. 3. The individual can cannot be reasonably expected within the near future to intentionally or uninte ntionally seriously physically injure self or others and has overtly acted in a ma nner substantially supportive of that expectation. I base my conclusion on the following facts: 4. The individual requires immediate admission to a center in order to prev ent physical harm to self and others pending hearing.Date Signature Name and title On I examined the individual and report that: Date 1. The individual does does not meet the criteria for judicial admission to a center. 2. My diagnosis is that the individual does does not have mental retardation. 3. The individual can cannot be reasonably expected within the near future to intentionally or uninte ntionally seriously physically injure self or others and has overtly acted in a ma nner substantially supportive of that expectation. I base my conclusion on the following facts: 4. The individual requires immediate admission to a center in order to prev ent physical harm to self and others pending hearing.Date Signature Name and title (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only American LegalNet, Inc. www.USCourtForms.com MCL 330.1516; MSA 14.800(516),PCM 215a (9/97) CERTIFCATION AND REPORT ON PETITION FOR JUDICIAL ADMISSION MCR 5.741<<<<<<<<<********>>>>>>>>>>>>> 2 REPORT ON PETITION FOR JUDICIAL ADMISSION 1. I, , as Name Profession, organization, and title have met with and evaluated the individual and report that his/her menta l, physical, social, and educational condition is: 2. The following is a list of available forms of care and treatment that ma y serve as an alternative to admission to a center. a. Residential placement: Availability (specify): b. Day activity programs: Availability (specify): c. Outpatient treatment: Availability (specify): d. Custody of friend or relative: Availability (specify): e. Home care or homemaker services: Availability (specify): f. Inpatient treatment at private psychiatric hospital: Name of hospital Availability (specify): g. Other: Availability (specify): 3. I recommend the most appropriate living arrangement for the individual i n terms of type and location and the availability of support services to be .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 Address Signature City, state, zip Telephone no. American LegalNet, Inc. www.USCourtForms.com

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