Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT COURT
COUNTY

PETITION FOR CONTINUED COMMITMENT
FOR TREATMENT OF INFECTIOUS DISEASE
AND ORDER TO RECONVENE
COMMITMENT REVIEW PANEL

CASE NO.

In the matter of

1. I am  director of the

Name of facility

2. The above named individual was committed to this facility for a period of

        by court order

Number of days or months

dated

.

3. The individual requires continued commitment for the following reasons:

    .

I REQUEST   that the court issue an order to continue commitment of the individual at the above named facility for a period of

Number of days or months

and under the conditions set by the court.

I declare that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and
belief.

Date

Signature of director

Name (type or print)

1. Date of Hearing:

Address

City, state, zip

ORDER

Judge:

, and

Telephone no.

    ,

IT IS ORDERED:
2. The previously appointed commitment review panel consisting of

shall reconvene and report to the court in writing within 14 days of the filing of this petition.

3. The panel shall do the following:

a. Review the petition and any other information considered relevant by the commitment review panel.
b. Interview the individual, or document the reasons why the individual was not interviewed.
c. Recommend to the circuit court either termination or continuation of the commitment and document reasons for the

recommendation.

Date

Judge

Do not write below this line - For court use only

PC 115  (6/98)   PETITION FOR CONTINUED COMMITMENT FOR TREATMENT OF INFECTIOUS DISEASE AND

ORDER TO RECONVENE COMMITMENT REVIEW PANEL

MCL 333.5205(4)(h); MSA 14.15(5205(6)(h), MCR 5.782