PCS Code: PFH/PAS/APM
TCS Code: IPFH/PFH/PAS/APM
SRA
XXX-XX-
Put last 4 digits of SSN in
Ref. No. row 2 on MC 97.
Put DOB in Ref. No.
row 1 on MC 97.
PETITION FOR MENTAL
HEALTH TREATMENT
STATE OF MICHIGAN
PROBATE COURT
COUNTY
Court address
Court telephone number
First, middle, and last name
Last 4 digits of SSN
Court ORI Date of birth
Put DOB in Ref. No.
row 1 on MC 97
Date of Birth Put Date of Birth in
Reference Number row 1 on MC 97
Date of Birth Put Date of Birth in
Reference Number row 1 on MC 97
Driver's license number. Put
Driver's license number in reference
number row 3 on MC 97
Driver's license no.
Put DLN in Ref. No.
row 3 on MC 97
Place of birth
Race Sex
In the matter of
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
County at
Street address City, state, zip
and can presently be found at
Facility name or other address
This petition is for a person who was found not guilty by reason of insanity in this county (NGRI).
3. I believe the individual has mental illness and
a. as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or
unintentionally seriously physically injure self or others, and has engaged in an act or acts or made significant
threats that are substantially supportive of this expectation.
b. as a result of that mental illness, the individual is unable to attend to those basic physical needs that must be
attended to in order to avoid serious harm in the near future, and has demonstrated that inability by failing to
attend to those basic physical needs.
c. the individual's judgment is so impaired by that mental illness, and whose lack of understanding of the need for treatment
has caused him or her to demonstrate an unwillingness to voluntarily participate in or adhere to treatment that is
necessary, on the basis of competent clinical opinion, to prevent a relapse or harmful deterioration of his or her
condition, and presents a substantial risk of significant physical or mental harm to the individual or others.
4. The conclusions stated above are based on
a. my personal observation of the person doing the following acts and saying the following things:
b. the following conduct and statements that others have seen or heard and have told me about:
by:
Witness name Complete address Telephone no.
Approved, SCAO
Form PCM 201, Rev. 3/23
MCL 330.1100a, MCL 330.1401, MCL 330.1423, MCL 330.1427,
MCL 330.1434, MCL 330.1438, MCL 330.2050, MCR 5.125(C)(18)
Page 1 of 2
Choose one of the following 3 options:
CASE NUMBER and JUDGE
AMENDED
Petition for Mental Health Treatment (3/23)
Page 2 of 2
Case Number
NAME RELATIONSHIP ADDRESS TELEPHONE
Spouse
Guardian*
5. The persons interested in these proceedings are:
*(Specify the county where the guardianship was established and the case number.)
6. The individual is
is not a veteran.
7. Attached is a
clinical certificate by a physician or licensed psychologist taken within the last 72 hours.
clinical certificate by a psychiatrist taken within the last 72 hours.
no clinical certificate is attached because only assisted outpatient treatment is requested.
8. (For hospitalization and combined treatment only.) An examination could not be secured because:
I request:
a. the individual be examined at
,
the preadmission screening unit or hospital designated by the community mental health services program.
b. a peace officer take the individual into protective custody. After the individual is taken into protective custody, a
peace officer or security transport officer shall transport the individual to
9. I request the court to determine the individual to be a person requiring treatment and to order:
a. hospitalization only.
b. a combination of hospitalization and assisted outpatient treatment.
c. assisted outpatient treatment without hospitalization.
10. I request the individual be hospitalized pending a hearing.
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 Date
Name (type or print) Bar no.
Address
City, state, zip Telephone no.
Signature of petitioner
Address
City, state, zip
Home telephone no. Work telephone no.
This petition for mental health treatment was received by the hospital on
Date
at
Time
Signature of hospital representative
FOR
HOSPITAL
USE ONLY
Choose an option:
Choose one of the following three options:
Choose an option:
.
