In the matter of 

First, middle, and last name

 

TO THE EXAMINER: You must read the following statement to the individual before proceeding 
with any questions.

I am authorized by law to examine you for the purpose of advising the court if you have a mental condition 
which needs treatment and whether such treatment should take place in a hospital or in some other place. 
I am also here to determine if you should be hospitalized or remain hospitalized before a court hearing is 
held. I may be required to tell the court what I observe and what you tell me.

. I am a 

  psychiatrist. 

  licensed psychologist. 

  physician.

2. I certify that on this date I read the above statement to the individual before asking any questions or conducting any examination.

3. I further certify that I, 

Name (type or print)

 , personally examined 

Patient

Name and address where examination took place

 starting at 

Time

 and continuing for 
 

 minutes.

 
INSTRUCTIONS:  Describe in detail the specific actions, statements, demeanor, and appearance of the individual, together 
with  other  information  which  underlie  your  conclusion.  Indicate  the  source  of  any  information  not  personally  known  or 
observed. If this certificate is to accompany a petition for discharge, state why the individual continues to be or is no longer a 
person requiring treatment or in need of hospitalization.

 mentally ill (has a substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize

4. My determination is that the person is
 
 
 

 not mentally ill.

  reality, or ability to cope with the ordinary demands of life).

 5. (if applicable) The person has
 
 
 

 convulsive disorder. 
 mental processes weakened by reason of advanced years.
 other (specify): 

  alcoholism. 

 

 

  other drug dependence. 

 

 

 

6. My diagnosis is: 

 

 

7. Facts serving as the basis for my determination are: 

 

  at 

 

on 

Date

  1

 
 
 

 

 

   

 

 

 

Approved, SCAODo not write below this line - For court use only(SEE SECOND PAGE)STATE OF MICHIGANPROBATE COURTCOUNTY OF CLINICAL CERTIFICATEFILE NO.PCM 208 (12/19) CLINICAL CERTIFICATEMCL 330.1435, MCL 330.1750PCS CODE: CCTTCS CODE: CCT 
 

 

 
 

 

 
 
 

 

 
 
 
 
 

 

 

8. Explain in the space below the facts which lead you to believe that future conduct may result in (check applicable box)
 

 a. likelihood of injury to self.  Facts:

File No. 
 

    Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near
    future to intentionally or unintentionally seriously physically injure self.

 b. likelihood of injury to others.  Facts:

    Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near
    future to intentionally or unintentionally seriously physically injure others.

 c.  inability to attend to basic physical needs.  Facts:

    Therefore, I believe that the examined person, as a result of mental illness, is unable to attend to those basic physical
    needs (such as food, clothing or shelter) that must be attended to in order to avoid serious harm in the near future
    and has demonstrated that inability by failing to attend to those basic physical needs.

 d. inability to understand need for treatment.  Facts:

    Therefore, I believe that the examined person, as a result of mental illness, is so impaired by that mental illness and 
    whose lack of understanding of the need for treatment has caused him or her to demonstrate an unwillingness to 
    voluntarily participate in or adhere to treatment that is necessary, on the basis of competent clinical opinion, to prevent 
    a relapse or harmful deterioration of his or her condition, and presents a substantial risk of significant physical or 
    mental harm to himself/herself or others.

9. I conclude the individual 

  is 

 

  is not 

  a person requiring treatment.

10.  (optional)  I recommend 
 
 
 
 

         
         

 
 

 
 

 hospitalization only 
 a combination of hospitalization and assisted outpatient treatment 
 assisted outpatient treatment without hospitalization 

 

 

 

  as follows: 
 

 

 

I certify that I am a person authorized by law to certify as to the individual's mental condition. I am not related by blood or 
marriage either to the person about whom this certificate is concerned or to any person who has filed, or whom I know to be 
planning to file, a petition in this proceeding.  I declare under the penalties of perjury that this certificate has been examined by 
me and that its contents are true to the best of my information, knowledge, and belief.

Date

Time of signing

 

 

 

 

 

 

 

 

 

 

 

 

Signature

Print or type name and business telephone no.

 .

Clinical Certificate (12/19)