STATE OF MICHIGAN

JUDICIAL CIRCUIT - FAMILY DIVISION
COUNTY

ORDER REGARDING 
QUALIFIED RESIDENTIAL TREATMENT 
PROGRAM PLACEMENT
 EX PARTE

CASE NO.

PETITION NO.

JUDGE

Court address

Court telephone no.

 1. The needs of the child cannot be met in a foster family home, placement of the child in a qualified residential treatment 
    program provides the most effective and appropriate level of care for the child in the least restrictive environment, and 
    is consistent with the goals in the permanency plan for the child.

 2. The needs of the child can be met in a foster family home, placement of the child in a qualified residential treatment 
    program does not provide the most effective and appropriate level of care for the child in the least restrictive 
    environment, and is not consistent with the goals in the permanency plan for the child.

In the matter of 

First and last name(s), alias(es)

HE COURT FINDS:

 3. Other:

IT IS ORDERED:

  T

 
 

 
 

4. After thorough consideration of the assessment made by the qualified individual, the child’s placement in a qualified  
 

residential treatment program is 

 not approved.

 approved. 

 

 

 

                     

Recommended by:

Referee signature and date

 

                     

Judge signature and date

 

 

Approved, SCAOForm JC 15o, Rev. 12/22MCL 712A.13a(17), MCL 712A.17, MCL 712A.18d, MCL 712A.19(10), MCL 712A.21, MCL 722.123a, MCL 712B.9, MCR 3.923(G), MCR 3.932(C)(9), MCR 3.942(A), MCR 3.945(A), MCR 3.966, MCR 3.972(A), MCR 3.975(H), MCR 3.992Page 1 of 1