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CERTIFICATION OF EXAMINERS

, I examined the individual and report that:

meet the criteria for treatment.

does

does not

have an intellectual disability.

seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation.

b. has been arrested and charged with an offense that was a result of the intellectual disability.

be reasonably expected within the near future to intentionally or unintentionally

4. The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending
hearing.

Signature

Name and title

, I examined the individual and report that:

meet the criteria for treatment.

does

does not

have an intellectual disability.

seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation.

b. has been arrested and charged with an offense that was a result of the intellectual disability.

be reasonably expected within the near future to intentionally or unintentionally

In the matter of

First, middle, and last name

Date

does

1. The individual

2. My diagnosis is that the individual
3. The individual
can

cannot

does not

I base my conclusion on the following facts:

Date

does

1. The individual

2. My diagnosis is that the individual
3. The individual
can

cannot

does not

I base my conclusion on the following facts:

4. The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending
hearing.

Date

Signature

Name and title

Do not write below this line - For court use onlyPCM 215a (2/19) CERTIFICATION AND REPORT ON PETITION FOR JUDICIAL ADMISSIONMCL 330.1516, MCR 5.741Approved, SCAO JIS CODE: CJASTATE OF MICHIGANPROBATE COURTCOUNTY OFCERTIFICATION AND REPORT ONPETITION FOR JUDICIAL ADMISSIONFILE NO.(PLEASE SEE OTHER SIDE)REPORT ON PETITION FOR JUDICIAL ADMISSION

File No.

1. I,

Name

, as

Profession, organization, and title

have met with and evaluated the individual and report that his/her mental, physical, social, and educational condition is:

2. The following is a list of available forms of care and treatment that may serve as an alternative to admission to a facility.

a. Residential placement:

Availability (specify):

b. Day activity programs:

Availability (specify):

c. Outpatient treatment:

Availability (specify):

d. Custody of friend or relative:

Availability (specify):

e. Home care or homemaker services:

Availability (specify):

g. Other:

Availability (specify):

support services to be

Date

Signature

f. Inpatient treatment at private psychiatric hospital:

Name of hospital

3. I recommend the most appropriate living arrangement for the individual in terms of type and location and the availability of

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

Address

City, state, zip Telephone no.

Certification and Report on Petition for Judicial Admission (2/19)

PCM 215a, Certification and Report on Petition for Judicial Admission

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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): 59
Average fields per page: 29
Reading Level: Grade 14
LIST Grouping(s): HE-03-00-00-00, 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_n_cour_count was STATE OF MICHIGAN PROBATE COURT COUNTY OF (0.67 conf)
first_middle_last_name was First middle and last name (0.37 conf)
signature_date__1 was Date (1.00 conf)
does was does (0.45 conf)
does_not was does not (0.45 conf)
does_2 was does_2 (0.39 conf)
does_not_2 was does not_2 (0.41 conf)
a was a (0.32 conf)
can was can (0.39 conf)
cannot__1 was cannot (0.42 conf)
b__1 was b (0.34 conf)
conclusion_following_facts__1 was I base my conclusion on the following facts 1 (0.34 conf)
conclusion_following_facts__2 was I base my conclusion on the following facts 2 (0.34 conf)
immediate_prevent_harm__1 was 4 The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending (0.38 conf)
signature_date__2 was Date_2 (1.00 conf)
name_title__1 was Name and title (0.40 conf)
signature_date__3 was Date_3 (1.00 conf)
does_3 was does_3 (0.39 conf)
does_not_3 was does not_3 (0.41 conf)
does_4 was does_4 (0.39 conf)
does_not_4 was does not_4 (0.41 conf)
a_2 was a_2 (0.35 conf)
can_2 was can_2 (0.34 conf)
cannot__2 was cannot_2 (0.41 conf)
b__2 was b_2 (0.29 conf)
conclusion_following_facts__3 was I base my conclusion on the following facts 1_2 (0.33 conf)
conclusion_following_facts__4 was I base my conclusion on the following facts 2_2 (0.33 conf)
immediate_prevent_harm__2 was 4 The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending_2 (0.40 conf)
signature_date__4 was Date_4 (1.00 conf)
name_title__2 was Name and title_2 (0.36 conf)
text__1 was Text1 (0.35 conf)
text__2 was Text2 (0.35 conf)
1_i was 1 I (0.32 conf)
as was as (0.32 conf)
report_physical_educational__1 was have met with and evaluated the individual and report that hisher mental physical social and educational condition is 1 (0.39 conf)
report_physical_educational__2 was have met with and evaluated the individual and report that hisher mental physical social and educational condition is 2 (0.39 conf)
report_physical_educational__3 was have met with and evaluated the individual and report that hisher mental physical social and educational condition is 3 (0.39 conf)
residential_placement was a Residential placement (0.44 conf)
availability_specify__1 was Availability specify (0.35 conf)
availability_specify__2 was Availability specify_2 (0.33 conf)
availability_specify__3 was Availability specify_3 (0.33 conf)
custody_friend_relative was d Custody of friend or relative (0.33 conf)
availability_specify__4 was Availability specify_4 (0.33 conf)
e_home_care_homemaker_services was e Home care or homemaker services (0.45 conf)
availability_specify__5 was Availability specify_5 (0.33 conf)
treatment_psychiatric_hospital was f Inpatient treatment at private psychiatric hospital (0.42 conf)
availability_specify__6 was Availability specify_6 (0.33 conf)
g was g Other (0.32 conf)
availability_specify__7 was Availability specify_7 (0.33 conf)
support_services was support services to be (0.43 conf)
signature_date__5 was Date_5 (1.00 conf)
users1_address_line_one was Address (1.00 conf)
telephone was Telephone no (0.44 conf)
b_day_activity_programs was b Day activity programs (0.40 conf)
textbox__1 was textbox100 (0.35 conf)
c_outpatient_treatment was c Outpatient treatment (0.38 conf)
textbox__2 was textbox101 (0.35 conf)
users1_address_line_two was City state zip (1.00 conf)
textbox__3 was textbox3 (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 215a, Certification and Report on Petition for Judicial Admission

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