In the matter of

1. Date of hearing:

THE COURT FINDS:

4.

Name

Approved, SCAO

STATE OF MICHIGAN

PROBATE COURT
COUNTY
CIRCUIT COURT - FAMILY DIVISION

ORDER FOR PLACEMENT OF
INDIVIDUAL WITH
DEVELOPMENTAL DISABILITY

JIS CODE:  OPI

FILE NO.

2. The guardian has filed a petition requesting authority to execute an application for admission of the individual to a facility.

, an individual with a developmental disability

Judge:

Bar no.

3. Notice of hearing was given to or waived by all interested persons.

is the guardian of the person for the individual named above.

5. From testimony given in open court and from the report and evaluation filed with the court, the individual requires care and

services at

Name of facility

.

6. The placement offers appropriate treatment and residential programs to meet the individual's need.

7. There appears to be no less restrictive treatment and residential program available to meet the individual's needs.

IT IS ORDERED:

8. The guardian is authorized to execute the necessary application for the

temporary administrative admission not to exceed 30 days
administrative admission
admission

of the individual named above to

Name of facility

Date

Judge

  .

Do not write below this line - For court use only

PC 665  (9/07)   ORDER FOR PLACEMENT OF INDIVIDUAL WITH DEVELOPMENTAL DISABILITY

MCL 330.1623, MCR 5.746(B)



Order for Placement of Individual with Developmental Disability

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About This Form:

• Sourced from www.courts.michigan.gov/guardianship (2023-03)
• Page(s): 1
• Fields(s): 13
• Average fields per page: 13
• Reading Level: Grade 11
• LIST Grouping(s): CO-00-00-00-00, CO-07-00-00-00.

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