STATE OF MICHIGAN

PROBATE COURT
COUNTY
CIRCUIT COURT - FAMILY DIVISION

REPORT TO ACCOMPANY PETITION TO
APPOINT, MODIFY OR DISCHARGE
GUARDIAN OF INDIVIDUAL WITH
DEVELOPMENTAL DISABILITY

OSM CODE: RPD

FILE NO.

    , an individual with an alleged developmental disability

, report to the court that:

2. The individual's developmental disability may be described as follows:

3. The appended evaluations are current, take into account the individual's abilities, and were performed and signed by the

    Name

   Title

Date Performed

Approved, SCAO

In the matter of

1. I,

Name (type or print)

Nature:

Type:

following individuals:
Evaluation

Mental

Physical

Social

Educational

Adaptive Behavior

Social Skills

4. Appended to the report is a listing of all psychotropic medication, plus all other medication that the individual is receiving on
a continuous basis, the dosage of the medication, and a description of the impact upon his or her mental, physical and
educational condition, adaptive behavior, and social skills.

5. Guardianship

for the following reason(s):

should be modified
is needed
is not needed.

PLEASE SEE OTHER SIDE

Do not write below this line - For court use only

PC 659   (3/00)   REPORT TO ACCOMPANY PETITION TO APPOINT, MODIFY OR DISCHARGE GUARDIAN OF INDIVIDUAL
MCL 330.1612; MSA 14.800(612)

WITH DEVELOPMENTAL DISABILITY

6. The type and scope of guardianship services needed are as follows:

7. The recommendations and reasons for the most appropriate rehabilitation plan are as follows:

8. The recommendations and reasons for the most appropriate living arrangements are as follows:

The guardian should be authorized to make application to place the individual in

Name or type of facility

    .

Date

Signature of person preparing report

Name of center or agency

Address

City, state, zip

Telephone no.