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STATE OF MICHIGAN

CASE NO. and JUDGE

PROBATE COURT
COUNTY

PETITION FOR CONTINUING MENTAL
HEALTH TREATMENT ORDER

Court address

Court telephone no.

the authorized representative of the agency or mental health professional supervising the individual’s assisted

In the matter of

First, middle, and last name

1. I,

Name (type or print)

outpatient treatment program.

Director or authorized representative

2. The individual is currently

3. The

second

, state that I am

Name of hospital

residing

hospitalized

Address and telephone no.

continuing

order entered by this court for the individual expires on

Date

4. The individual continues to be a person requiring treatment and is in need of

hospitalization for not more than one year.
continuing hospitalization for a period of one year.
combined hospitalization and assisted outpatient treatment for not more than one year.
assisted outpatient treatment for not more than one year.

5. The individual is likely to refuse treatment on a voluntary basis when the order expires.

INSTRUCTIONS: In answering items 6 and 7, include a description of the observed or reported behavior of the individual
including, but not limited to, how behavior and conditions have changed since the last order and whether any stabilization
or remission is contingent on continued medication or other treatment. Avoid medical terms and conclusions other than
diagnosis.

b. as a result of that mental illness, the individual is unable to attend to those basic physical needs that must be

a. as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or

unintentionally seriously physically injure self or others, and has engaged in an act or acts or made significant
threats that are substantially supportive of this expectation.

6. The basis for this allegation is that I believe the individual has a mental illness and: (Check all that apply.)

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 the
individual or others.

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.

c. the individual’s judgment is so impaired by that mental illness and whose lack of understanding of the need for

Approved, SCAO
Form PCM 218a, Rev. 6/21
MCL 330.1472a, MCL 330.1473
Page 1 of 2

PCS Code: PCTTCS Code: PCOWitness name Complete address Telephone no.

8. The diagnoses of mental conditions are

9. The treatment program(s) provided to the individual thus far, and the results, are

10. The present treatment
is

The individual

is
is not

is not
motivated to participate in this treatment program. The estimate of further

adequate and appropriate to the individual's condition.

time necessary to provide the required treatment is
.

The following modifications are currently planned for the next period of treatment: (Write "none" if no modifications are expected.)

11. The interested parties, their addresses, and their representatives are identical to those appearing on the initial petition

except as follows:

12. Attached is a clinical certificate executed by a psychiatrist.

13. I REQUEST the court to order the individual to receive

hospitalization for not more than one year.
continuing hospitalization for not more than one year.
combined hospitalization and assisted outpatient treatment for not more than one year.
assisted outpatient treatment for not more than one year.

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.

Date

Address

Signature of petitioner

City, state, zip

Telephone no.

by:

Petition for Continuing Mental Health Treatment Order
Page 2 of 2

(6/21)

Case No.

7. This conclusion is based upon

a. my personal observation of the person doing the following acts and saying the following things:

b. the following conduct and statements that others have seen or heard and have told me about:

PCM 218a, Petition for Continuing Mental Health Treatment Order

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Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.courts.michigan.gov/MH-Forms (2023-03)
Page(s): 2
Fields(s): 53
Average fields per page: 26
Reading Level: Grade 14
LIST Grouping(s): HE-03-00-00-00, ES-05-00-00-00, HE-00-00-00-00.

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

stat_e_f_michiga_n_probat_cour_county was STATE OF MICHIGAN PROBATE COURT COUNTY (0.62 conf)
court_address was Court address (0.42 conf)
first_middle_last_name was First middle and last name (0.37 conf)
name_type_print was Name type or print (0.45 conf)
authorized_representative was Director or authorized representative (0.46 conf)
name_hospital was Name of hospital (0.35 conf)
residing was residing (0.24 conf)
hospitalized was hospitalized (0.37 conf)
address_telephone was Address and telephone no (0.42 conf)
undefined__1 was undefined_2 (0.39 conf)
second was second (0.34 conf)
continuing was continuing (0.33 conf)
signature_date__1 was Date (1.00 conf)
hospitalization_one_year__1 was hospitalization for not more than one year (0.32 conf)
continuing_hospitalization_period was continuing hospitalization for a period of one year (0.29 conf)
combined_hospitalization_treatment__1 was combined hospitalization and assisted outpatient treatment for not more than one year (0.31 conf)
outpatient_treatment_year__1 was assisted outpatient treatment for not more than one year (0.25 conf)
expected_within_near was a as a result of that mental illness the individual can reasonably be expected within the near future to intentionally or (0.33 conf)
individual_unable_physical_must was b as a result of that mental illness the individual is unable to attend to those basic physical needs that must be (0.35 conf)
illness_lack_understanding was c the individuals judgment is so impaired by that mental illness and whose lack of understanding of the need for (0.38 conf)
judge was Judge (0.39 conf)
text__1 was Text2 (0.35 conf)
representative_agency was the authorized representative of the agency or mental health professional supervising the individuals assisted (0.39 conf)
checkbox was CHECKBOX (0.35 conf)
person_saying_things__1 was a my personal observation of the person doing the following acts and saying the following things 1 (0.42 conf)
person_saying_things__2 was a my personal observation of the person doing the following acts and saying the following things 2 (0.42 conf)
statements_others_seen_heard_told__1 was b the following conduct and statements that others have seen or heard and have told me about 1 (0.41 conf)
statements_others_seen_heard_told__2 was b the following conduct and statements that others have seen or heard and have told me about 2 (0.41 conf)
witness_name was Witness name (0.46 conf)
complete_address was Complete address (0.35 conf)
telephone was Telephone no (0.44 conf)
undefined__2 was undefined_3 (0.39 conf)
diagnoses_mental_conditions was 8 The diagnoses of mental conditions are (0.42 conf)
undefined__3 was undefined_4 (0.39 conf)
provided_individual_far__1 was 9 The treatment programs provided to the individual thus far and the results are 1 (0.36 conf)
provided_individual_far__2 was 9 The treatment programs provided to the individual thus far and the results are 2 (0.36 conf)
undefined__4 was undefined_5 (0.39 conf)
is was is (0.32 conf)
is_not was is not (0.34 conf)
is_2 was is_2 (0.35 conf)
is_not_2 was is not_2 (0.39 conf)
participate_program_estimate was motivated to participate in this treatment program The estimate of further (0.32 conf)
period_none_expected__1 was The following modifications are currently planned for the next period of treatment Write none if no modifications are expected 1 (0.32 conf)
period_none_expected__2 was The following modifications are currently planned for the next period of treatment Write none if no modifications are expected 2 (0.32 conf)
hospitalization_one_year__2 was hospitalization for not more than one year_2 (0.27 conf)
continuing_hospitalization_year was continuing hospitalization for not more than one year (0.30 conf)
combined_hospitalization_treatment__2 was combined hospitalization and assisted outpatient treatment for not more than one year_2 (0.30 conf)
outpatient_treatment_year__2 was assisted outpatient treatment for not more than one year_2 (0.31 conf)
information_knowledge_belief was of my information knowledge and belief (0.30 conf)
undefined__5 was undefined_6 (0.39 conf)
signature_date__2 was Date_2 (1.00 conf)
text__2 was Text3 (0.35 conf)
text__3 was Text4 (0.35 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

PCM 218a, Petition for Continuing Mental Health Treatment Order

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02