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Here is the text we could read:

In the matter of 

First, middle, and last name

 

Attached is my clinical certificate (form PCM 208) setting forth why the above person requires treatment. I further certify and 
report as follows.

1. The reason(s) for this individual's return to the hospital or facility from authorized leave, and the need for treatment in a hospital 

2. The plans for further treatment of the individual are 

 

3. Should the court rule against the return of this individual, I recommend the court consider the following alternatives instead 
  of a return to authorized leave status, if any of these options are available.
 
 
 
 
 

 Day treatment in a hospital or facility 
 Residential placement 
 Inpatient treatment at a private psychiatric hospital, 
  at a general hospital's psychiatric unit, or a private 
 

 Night treatment in a hospital or facility
 Custody of a friend or relative
 Assisted outpatient treatment
 Home care or homemaker service
 Day activity programs

residential facility 

 None of the above merits exploration. 

State reasons

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 

 

 

Signature

 

 

Title (physician, psychiatrist, licensed psychologist)

or facility are 

 

 

 

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

   

 

 

 Other: 
 

 

 

 

Approved, SCAODo not write below this line - For court use onlySTATE OF MICHIGANPROBATE COURTCOUNTY OF SUPPLEMENT TO CLINICAL CERTIFICATEON APPEAL OF RETURN TO HOSPITAL/FACILITYFILE NO.PCM 208a (2/19) SUPPLEMENT TO CLINICAL CERTIFICATE ON APPEAL OF RETURN TO HOSPITAL/FACILITYMCR 5.743aPCS CODE: PCATCS CODE: PCA

PCM 208a, Supplement to Clinical Certificate on Appeal of Return to Hospital/Facility

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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): 1
Fields(s): 29
Average fields per page: 29
Reading Level: Grade 12
LIST Grouping(s): HE-00-00-00-00, HE-03-00-00-00.

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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_n_cour_count was STATE OF MICHIGAN PROBATE COURT COUNTY OF (0.67 conf)
fil_e was FILE NO (0.48 conf)
first_middle_last_name was First middle and last name (0.37 conf)
reasons_need_treatment was 1 The reasons for this individuals return to the hospital or facility from authorized leave and the need for treatment in a hospital (0.43 conf)
facility__1 was or facility are 1 (0.34 conf)
facility__2 was or facility are 2 (0.34 conf)
facility__3 was or facility are 3 (0.34 conf)
undefined__1 was undefined (0.38 conf)
plans_treatment_individual__1 was 2 The plans for further treatment of the individual are 1 (0.31 conf)
plans_treatment_individual__2 was 2 The plans for further treatment of the individual are 2 (0.31 conf)
plans_treatment_individual__3 was 2 The plans for further treatment of the individual are 3 (0.31 conf)
day_treatment_hospital was Day treatment in a hospital or facility (0.41 conf)
residential_placement was Residential placement (0.34 conf)
private_psychiatric_hospital was Inpatient treatment at a private psychiatric hospital (0.44 conf)
other was Other (0.43 conf)
none_merits_exploration was None of the above merits exploration (0.35 conf)
night_treatment_hospital was Night treatment in a hospital or facility (0.40 conf)
custody_friend_relative was Custody of a friend or relative (0.38 conf)
assisted_outpatient_treatment was Assisted outpatient treatment (0.39 conf)
home_care_homemaker_service was Home care or homemaker service (0.47 conf)
day_activity_programs was Day activity programs (0.37 conf)
residential_facility was residential facility (0.44 conf)
undefined__2 was undefined_2 (0.39 conf)
state_reasons__1 was State reasons 1 (0.42 conf)
state_reasons__2 was State reasons 2 (0.42 conf)
information_knowledge_belief was of my information knowledge and belief (0.30 conf)
title_psychiatrist_psychologist was Title physician psychiatrist licensed psychologist (0.33 conf)
text__1 was Text1 (0.35 conf)
text__2 was Text2 (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 208a, Supplement to Clinical Certificate on Appeal of Return to Hospital/Facility

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

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