Form PCM201 "Petition for Mental Health Treatment" - Michigan

What Is Form PCM201?

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 December 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 PCM201 by clicking the link below or browse more documents and templates provided by the Michigan Probate Court.

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Download Form PCM201 "Petition for Mental Health Treatment" - Michigan

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PCS CODE: PFH/PAS/APM
Approved, SCAO
TCS CODE: IPFH/PFH/PAS/APM
STATE OF MICHIGAN
FILE NO.
PETITION FOR MENTAL
PROBATE COURT
HEALTH TREATMENT
COUNTY OF
AMENDED
XXX-XX-
In the matter of
First, middle, and last name
Last four digits of SSN
Court ORI
Date of birth
Place of birth
Race
Sex
1. I,
, an adult
petition because
Name (type or print)
specify whether a relative, neighbor, peace officer, etc.
I believe the individual named above needs treatment.
2. The individual was born
, has a permanent residence in
Date
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.
(SEE SECOND PAGE)
Do not write below this line - For court use only
MCL 330.1100a(29), MCL 330.1401, MCL 330.1423, MCL 330.1427,
PETITION FOR MENTAL HEALTH TREATMENT
PCM 201 (12/19)
MCL 330.1434, MCL 330.1438, MCL 330.2050, MCR 5.125(C)(18)
PCS CODE: PFH/PAS/APM
Approved, SCAO
TCS CODE: IPFH/PFH/PAS/APM
STATE OF MICHIGAN
FILE NO.
PETITION FOR MENTAL
PROBATE COURT
HEALTH TREATMENT
COUNTY OF
AMENDED
XXX-XX-
In the matter of
First, middle, and last name
Last four digits of SSN
Court ORI
Date of birth
Place of birth
Race
Sex
1. I,
, an adult
petition because
Name (type or print)
specify whether a relative, neighbor, peace officer, etc.
I believe the individual named above needs treatment.
2. The individual was born
, has a permanent residence in
Date
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.
(SEE SECOND PAGE)
Do not write below this line - For court use only
MCL 330.1100a(29), MCL 330.1401, MCL 330.1423, MCL 330.1427,
PETITION FOR MENTAL HEALTH TREATMENT
PCM 201 (12/19)
MCL 330.1434, MCL 330.1438, MCL 330.2050, MCR 5.125(C)(18)
Petition for Mental Health Treatment (12/19)
File No.
5. The persons interested in these proceedings are:
NAME
RELATIONSHIP
ADDRESS
TELEPHONE
Spouse
Guardian*
*(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.
An examination could not be secured because:
(For hospitalization and combined treatment only.)
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 and 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.
Signature of petitioner
Address
Address
City, state, zip
Telephone no.
City, state, zip
Home telephone no.
Work telephone no.
This petition for mental health treatment was received by the hospital on
at
.
Date
Time
FOR
HOSPITAL
USE ONLY
Signature of hospital representative
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