PCS CODE: ORA/RAT
Approved, SCAO
TCS CODE: ORA/RAT
STATE OF MICHIGAN
FILE NO.
ORDER AND REPORT ON
PROBATE COURT
ALTERNATIVE MENTAL
COUNTY OF
HEALTH TREATMENT
In the matter of
First, middle, and last name
ORDER
IT IS ORDERED that
shall prepare a report assessing the current
Name (type or print)
availability and appropriateness of alternatives to hospitalization for the individual named above including alternatives available
following an initial period of court-ordered hospitalization.
The report shall be made to the court before the hearing on
for
Date and time of hearing
.
Petition for 60-day order, discharge, etc.
Date
Judge
Bar no.
REPORT ON EVALUATION OF HOSPITAL TREATMENT AND/OR ALTERNATIVE PROGRAMS
1. I,
, as
, report as follows.
Name
Profession, organization, and position
2. I have reviewed, as to their availability in or near the individual’s home community, treatment resources alternative to
hospitalization and report as follows:
(If practical, give name of agency, program, etc.)
a. Independent mental health professional:
b. Community mental health day treatment, aftercare service, work activity, or other program:
c. Substance abuse, rehabilitation service, or similar program of public or private agency:
d. Other:
(SEE SECOND PAGE)
Do not write below this line - For court use only
ORDER AND REPORT ON ALTERNATIVE MENTAL HEALTH TREATMENT
PCM 216 (9/16)
MCL 330.1453a, MCR 5.741
PCS CODE: ORA/RAT
Approved, SCAO
TCS CODE: ORA/RAT
STATE OF MICHIGAN
FILE NO.
ORDER AND REPORT ON
PROBATE COURT
ALTERNATIVE MENTAL
COUNTY OF
HEALTH TREATMENT
In the matter of
First, middle, and last name
ORDER
IT IS ORDERED that
shall prepare a report assessing the current
Name (type or print)
availability and appropriateness of alternatives to hospitalization for the individual named above including alternatives available
following an initial period of court-ordered hospitalization.
The report shall be made to the court before the hearing on
for
Date and time of hearing
.
Petition for 60-day order, discharge, etc.
Date
Judge
Bar no.
REPORT ON EVALUATION OF HOSPITAL TREATMENT AND/OR ALTERNATIVE PROGRAMS
1. I,
, as
, report as follows.
Name
Profession, organization, and position
2. I have reviewed, as to their availability in or near the individual’s home community, treatment resources alternative to
hospitalization and report as follows:
(If practical, give name of agency, program, etc.)
a. Independent mental health professional:
b. Community mental health day treatment, aftercare service, work activity, or other program:
c. Substance abuse, rehabilitation service, or similar program of public or private agency:
d. Other:
(SEE SECOND PAGE)
Do not write below this line - For court use only
ORDER AND REPORT ON ALTERNATIVE MENTAL HEALTH TREATMENT
PCM 216 (9/16)
MCL 330.1453a, MCR 5.741
Order and Report on Alternative Mental Health Treatment (9/16)
File No.
3. I have reviewed, as to their availability in or near the individual's home community, residential accommodations and report
as follows:
(If practical, give name of residence, location, etc.)
a. Independent:
Individual’s own house, apartment, etc.
b. Residence of relative or friend:
c. Foster care home:
d. Nursing home:
e. Other:
4. I recommend release.
5. I recommend a course of treatment of
hospitalization
hospitalization for
days, followed by
alternative treatment
assisted outpatient treatment
as follows:
6. My recommendation is based upon the following described interviews, observations, and information:
7. I believe the hospital to which admission is proposed
can
cannot
provide its prescribed treatment program
appropriately and adequately because
8. I recommend the following agency or independent mental health professional to supervise the alternative treatment:
Name
Complete address
The agency or professional
has
has not indicated capability and willingness to supervise the recommended program.
9. The individual currently has the following source(s) of funds to cover his or her care in the community:
10. The individual does not currently have sufficient sources of funds for community living.
a. Application for supplemental funds has been made. They should be available
.
b. Application for supplemental funds has not been made because
.
Application will be made on
and should be available about
.
c. Pending receipt of supplemental funds, the following funds will be available:
Direct relief.
DHHS/CMH emergency care funds.
Other assistance:
None. Reason:
Date
Signature
ADVERTISEMENT