Approved, SCAO

STATE OF MICHIGAN
PROBATE COURT
COUNTY OF

In the matter of

1.

I,

Name

PETITION FOR AUTHORITY TO PLACE
INDIVIDUAL WITH DEVELOPMENTAL
DISABILITY IN A FACILITY

FILE NO.

JIS CODE:  PDA

, an individual with a developmental disability

, am interested in this matter and make this petition as guardian of

the individual.
The individual is presently residing at

2.

Address

City

State

Zip

3.

It is necessary that I be authorized by this court to admit the individual

a. temporarily for a period not to exceed 30 days to

Name of center

to receive clinical services.

located at

b. to

Name of center

c. to

Name of facility

for up to 10 days for a preadmission examination and subsequent administrative admission if suitable.

4.

A report and evaluation required by law and court rule is filed with this petition.

5.

The following are all the interested persons in this proceeding, none of which are under legal disability except as noted:

NAME

AGE

RELATIONSHIP

ADDRESS AND TELEPHONE NUMBER

.

.

6. I REQUEST that I be authorized to execute the necessary applications for the administrative admission of the individual to

I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my
information, knowledge, and belief.

 State

Zip

 Telephone no.

 State

Zip

 Telephone no.

.

, located at

, located at

  Street  address

City

City

  Street  address

Bar no.

Petitioner signature

Date

Address

Name of facility

Attorney signature

Name (type or print)

Address

City, state, zip

 USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.

Telephone no.

City, state, zip

Telephone no.

Do not write below this line - For court use only

PC 664   (9/12)   PETITION FOR AUTHORITY TO PLACE INDIVIDUAL WITH DEVELOPMENTAL DISABILITY IN A FACILITY

MCL 330.1100b, MCL 330.1509,
MCL 330.1510, MCL 330.1623, MCR 5.746