Form PCM 217A Order to Modify Order for Alternative Treatment or Combined Hospitalization and Alternative Treatment - Michigan

Form PCM217A is a Michigan Probate Court form also known as the "Order To Modify Order For Alternative Treatment Or Combined Hospitalization And Alternative Treatment". The latest edition of the form was released in September 1, 2013 and is available for digital filing.

Download a PDF version of the Form PCM217A down below or find it on Michigan Probate Court Forms website.

ADVERTISEMENT
Approved, SCAO
JIS CODE: C9M
STATE OF MICHIGAN
ORDER TO MODIFY ORDER FOR
FILE NO.
ALTERNATIVE TREATMENT OR
PROBATE COURT
COUNTY OF
COMBINED HOSPITALIZATION AND
ALTERNATIVE TREATMENT
In the matter of
1. Date of hearing:
Judge:
Bar no.
2. This court issued an
initial
second
continuing
order on
directing the individual
Date
named above to undergo a program of alternative treatment or combined hospitalization and alternative treatment.
3. The court has been notified that
the individual is not complying with the order for alternative treatment or combined hospitalization and alternative treatment.
alternative treatment has not been or will not be sufficient to prevent harm or injury the individual may inflict upon self or others.
the individual believes that the alternative treatment program is not appropriate.
4. THE COURT FINDS:
IT IS ORDERED:
5. The order for alternative treatment or combined hospitalization and alternative treatment is modified and the individual shall
undergo a program of alternative treatment under the supervision of
a community mental health services program
a mental health agency or professional
as follows:
This alternative treatment shall not exceed the time from the date of issuance of the
initial
second
continuing
order.
6. The order for alternative treatment or combined hospitalization and alternative treatment is modified and the individual shall
be hospitalized at
for a period not to exceed the remainder of the previously-ordered hospitalization portion of the
initial
second
continuing
combined order.
(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only
ORDER TO MODIFY ORDER FOR ALTERNATIVE TREATMENT OR COMBINED HOSPITALIZATION
PCM 217a (9/13)
AND ALTERNATIVE TREATMENT
MCL 330.1475, MCR 5.744
Approved, SCAO
JIS CODE: C9M
STATE OF MICHIGAN
ORDER TO MODIFY ORDER FOR
FILE NO.
ALTERNATIVE TREATMENT OR
PROBATE COURT
COUNTY OF
COMBINED HOSPITALIZATION AND
ALTERNATIVE TREATMENT
In the matter of
1. Date of hearing:
Judge:
Bar no.
2. This court issued an
initial
second
continuing
order on
directing the individual
Date
named above to undergo a program of alternative treatment or combined hospitalization and alternative treatment.
3. The court has been notified that
the individual is not complying with the order for alternative treatment or combined hospitalization and alternative treatment.
alternative treatment has not been or will not be sufficient to prevent harm or injury the individual may inflict upon self or others.
the individual believes that the alternative treatment program is not appropriate.
4. THE COURT FINDS:
IT IS ORDERED:
5. The order for alternative treatment or combined hospitalization and alternative treatment is modified and the individual shall
undergo a program of alternative treatment under the supervision of
a community mental health services program
a mental health agency or professional
as follows:
This alternative treatment shall not exceed the time from the date of issuance of the
initial
second
continuing
order.
6. The order for alternative treatment or combined hospitalization and alternative treatment is modified and the individual shall
be hospitalized at
for a period not to exceed the remainder of the previously-ordered hospitalization portion of the
initial
second
continuing
combined order.
(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only
ORDER TO MODIFY ORDER FOR ALTERNATIVE TREATMENT OR COMBINED HOSPITALIZATION
PCM 217a (9/13)
AND ALTERNATIVE TREATMENT
MCL 330.1475, MCR 5.744
7. The order for alternative treatment or combined hospitalization and alternative treatment is modified and the individual shall
continue to undergo combined hospitalization and alternative treatment for the remainder of the previously-ordered period.
The individual shall be hospitalized at
for a period not to exceed the remainder of the initially ordered hospitalization portion of the
initial
second
continuing
combined order. Alternative treatment shall be under the supervision of
a community mental health services program
a mental health agency or professional
as follows:
NOTICE: The court must be promptly notified of the individual's release from the hospital to the alternative treatment program,
along with a psychiatrist's statement that the individual is clinically appropriate for alternative treatment.
8. If the individual refuses to comply with a psychiatrist's order to return to the hospital, a peace officer shall take the individual
into protective custody and transport the individual to the hospital designated by the psychiatrist.
9. This order expires on
.
Date
Date
Judge
NOTICE OF RIGHT TO OBJECT TO HOSPITALIZATION
If the court has ordered you to be hospitalized rather than continue in an alternative treatment program you have a right to object to
this hospitalization. If you wish to object, complete the objection below and send a copy to the court.
PROOF OF SERVICE
I certify that this notice was personally served on the individual named above on
at
Date
Time
and a copy was mailed to the
Court on
.
Date
Signature
OBJECTION TO HOSPITALIZATION
I object to my hospitalization and request that the court schedule a hearing on the objection.
Signature
Date

Download Form PCM 217A Order to Modify Order for Alternative Treatment or Combined Hospitalization and Alternative Treatment - Michigan

800 times
Rate
4.6(4.6 / 5) 48 votes
ADVERTISEMENT
Page of 2