In the matter of 

First, middle, and last name

1. On 

Date

 , after a hearing required by statute, the court found you to be a person requiring

 

treatment and entered an order for a program of assisted outpatient treatment.  

2. 
 

	a.	After	being	notified	that	
 

                               

 

 

 

	

	 the	assisted	outpatient	program	was	insufficient,	
  you did not comply with the assisted outpatient program,

	

the	court	entered	an	order	(form	PCM	217a)	that	resulted	in	your	hospitalization	and/or	placement	in	a	different		

  assisted outpatient treatment program.  A copy of the amended order (form PCM 217a) is attached.

	b.	The	court	has	been	notified	that	you	have	been	hospitalized	by	a	psychiatrist's	order	under	MCL	330.1474a.

NOTICE OF RIGHT TO OBJECT

 

	

 

	

 

 

TO: 
 

You are notified that	you	may	object	to	the	court's	or	psychiatrist's	order	to	hospitalize	you	by	completing	the	objection	below	

and	returning	it	to	the	court	no	later	than	7	days	after	receiving	this	notice.	The	court	will	schedule	a	hearing	within	10	days	after

receiving	your	objection.

I certify that on 

Date

Notice of Right to Object.

PROOF OF SERVICE

 at 

Time

	I	personally	served	this	notice	on	the	individual	named	in	the	

Date

Signature

OBJECTION TO HOSPITALIZATION AND DEMAND FOR HEARING

I object to my hospitalization and demand a hearing.  

 I request court-appointed legal counsel.

Date

 

 

 

 

 

 

 

Signature

Name (type or print)

 

 

Approved, SCAODo not write below this line - For court use onlySTATE OF MICHIGANPROBATE COURTCOUNTY OF NOTICE OF RIGHT TO OBJECT TO HOSPITALIZATION ANDOBJECTION AND DEMAND FOR HEARINGFILE NO.PCM 241 (2/19) NOTICE OF RIGHT TO OBJECT TO HOSPITALIZATION AND OBJECTION AND DEMAND FOR HEARINGMCL 330.1475a, MCR 5.744PCS CODE: NRRTCS CODE: NRTO