Form PCM209A "Order for Examination/Transport" - Michigan

What Is Form PCM209A?

This is a legal form that was released by the Michigan Probate Court - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2019;
  • The latest edition provided by the Michigan Probate Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PCM209A by clicking the link below or browse more documents and templates provided by the Michigan Probate Court.

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Download Form PCM209A "Order for Examination/Transport" - Michigan

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PCS CODE: OET
Approved, SCAO
TCS CODE: OET
STATE OF MICHIGAN
FILE NO.
PROBATE COURT
ORDER FOR
COUNTY OF
EXAMINATION/TRANSPORT
In the matter of
DOB:
First, middle, and last name
1. Date of hearing:
Judge:
Bar no.
THE COURT FINDS:
2. A petition alleging the individual is a person requiring treatment and requesting hospitalization or a combined treatment order
has been filed with the court, and
a. one clinical certificate accompanies the petition. The individual must be examined by a psychiatrist.
b. no clinical certificate accompanies the petition. A reasonable effort was made to secure an examination. The individual
must be examined by a psychiatrist and either a physician or a licensed psychologist.
3. The court has received information that a petition for assisted outpatient treatment has been filed, the petitioner has made
reasonable efforts to secure an examination, and the individual will not make himself/herself available for evaluation.
4. The individual requires immediate assessment because the individual presents a substantial risk of significant physical
or mental harm to himself/herself in the near future or presents a substantial risk of significant physical harm to others in
the near future.
5. There does not appear to be probable cause to order the individual be taken into protective custody and transported to
the designated prescreening unit or hospital.
IT IS ORDERED:
6. The individual be examined by a
psychiatrist.
psychiatrist and a physician or licensed psychologist
at
.
Prescreening unit or hospital
Upon completion of the examination(s), the executed clinical certificate(s) shall be filed with the court or a report that a
clinical certificate is not warranted shall be made to the court.
The individual shall be hospitalized. If the examinations and clinical certificates are not completed within 24 hours
after hospitalization, the individual shall be released.
A peace officer shall take the individual into protective custody and transport him/her to the designated
prescreening unit or hospital. If the order is not executed by
, the law enforcement
10 days from entry of order
agency must report to the court the reason the order was not executed within the prescribed time period.
7. A peace officer shall take the individual into protective custody and transport him/her to the designated
prescreening unit or hospital for assessment for assisted outpatient treatment. If the order is not
executed by
, the law enforcement agency must report to the court the reason the order
10 days from entry of order
was not executed within the prescribed time period.
8. The request to take the individual into protective custody for transport is denied.
Date
Judge
Bar no.
Do not write below this line - For court use only
ORDER FOR EXAMINATION/TRANSPORT
PCM 209a (2/19)
MCL 330.1435, MCL 330.1436, MCL 330.1437, MCL 330.1438
PCS CODE: OET
Approved, SCAO
TCS CODE: OET
STATE OF MICHIGAN
FILE NO.
PROBATE COURT
ORDER FOR
COUNTY OF
EXAMINATION/TRANSPORT
In the matter of
DOB:
First, middle, and last name
1. Date of hearing:
Judge:
Bar no.
THE COURT FINDS:
2. A petition alleging the individual is a person requiring treatment and requesting hospitalization or a combined treatment order
has been filed with the court, and
a. one clinical certificate accompanies the petition. The individual must be examined by a psychiatrist.
b. no clinical certificate accompanies the petition. A reasonable effort was made to secure an examination. The individual
must be examined by a psychiatrist and either a physician or a licensed psychologist.
3. The court has received information that a petition for assisted outpatient treatment has been filed, the petitioner has made
reasonable efforts to secure an examination, and the individual will not make himself/herself available for evaluation.
4. The individual requires immediate assessment because the individual presents a substantial risk of significant physical
or mental harm to himself/herself in the near future or presents a substantial risk of significant physical harm to others in
the near future.
5. There does not appear to be probable cause to order the individual be taken into protective custody and transported to
the designated prescreening unit or hospital.
IT IS ORDERED:
6. The individual be examined by a
psychiatrist.
psychiatrist and a physician or licensed psychologist
at
.
Prescreening unit or hospital
Upon completion of the examination(s), the executed clinical certificate(s) shall be filed with the court or a report that a
clinical certificate is not warranted shall be made to the court.
The individual shall be hospitalized. If the examinations and clinical certificates are not completed within 24 hours
after hospitalization, the individual shall be released.
A peace officer shall take the individual into protective custody and transport him/her to the designated
prescreening unit or hospital. If the order is not executed by
, the law enforcement
10 days from entry of order
agency must report to the court the reason the order was not executed within the prescribed time period.
7. A peace officer shall take the individual into protective custody and transport him/her to the designated
prescreening unit or hospital for assessment for assisted outpatient treatment. If the order is not
executed by
, the law enforcement agency must report to the court the reason the order
10 days from entry of order
was not executed within the prescribed time period.
8. The request to take the individual into protective custody for transport is denied.
Date
Judge
Bar no.
Do not write below this line - For court use only
ORDER FOR EXAMINATION/TRANSPORT
PCM 209a (2/19)
MCL 330.1435, MCL 330.1436, MCL 330.1437, MCL 330.1438
Order for Examination/Transport (2/19)
File No.
REPORT OF NON-EXECUTION
The Order for Examination/Transport issued on
has not been executed. The reason the order was
Date
not executed within 10 days after entry is:
Date
Name
Law enforcement agency
Telephone no.
TO THE LAW ENFORCEMENT AGENCY: Under MCL 330.1436(2), this report must be filed with the court that issued the
Order for Examination/Transport if the order is not executed within 10 days after entry of the order.
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