Bar no.

1. Date of hearing: 

 

  Judge: 

THE COURT FINDS:
2. A petition alleging the individual is a person requiring treatment and requesting hospitalization or a combined treatment order 
  has been filed with the court, and
 
 
 

 a. one clinical certificate accompanies the petition. The individual must be examined by a psychiatrist.
 b. no clinical certificate accompanies the petition. A reasonable effort was made to secure an examination. The individual

        must be examined by a psychiatrist and either a physician or a licensed psychologist.

 3. The court has received information that a petition for assisted outpatient treatment has been filed, the petitioner has made
    reasonable efforts to secure an examination, and the individual will not make himself/herself available for evaluation.

  

 4. The individual requires immediate assessment because the individual presents a substantial risk of significant physical  
    or mental harm to himself/herself in the near future or presents a substantial risk of significant physical harm to others in 
    the near future.

 5. There does not appear to be probable cause to order the individual be taken into protective custody and transported to  
    the designated prescreening unit or hospital.

T IS ORDERED:

 6. The individual be examined by a 
 

  at 

Prescreening unit or hospital

 

  psychiatrist. 

 

  psychiatrist and a physician or licensed psychologist 

 

 .

  Upon completion of the examination(s), the executed clinical certificate(s) shall be filed with the court or a report that a  
  clinical certificate is not warranted shall be made to the court. 

 The individual shall be hospitalized. If the examinations and clinical certificates are not completed within 24 hours  

 
    after hospitalization, the individual shall be released.

 A peace officer shall take the individual into protective custody and transport him/her to the designated 

 
    prescreening unit or hospital.  If the order is not executed by 

, the law enforcement 

10 days from entry of order

    agency must report to the court the reason the order was not executed within the prescribed time period.

 7.   A peace officer shall take the individual into protective custody and transport him/her to the designated 
 
 
 
 

  prescreening unit or hospital for assessment for assisted outpatient treatment.  If the order is not 
  executed by 
 
  was not executed within the prescribed time period.

10 days from entry of order

, the law enforcement agency must report to the court the reason the order 

 8. The request to take the individual into protective custody for transport is denied.

 
 

 

  I

 

 
 

 
 

 
 

 

 
 
 
 

 
 

 
 

 
 

 

Date

Judge 

 

 

 

Bar no.

 

 

 

In the matter of 

First, middle, and last name

  DOB: 
 

Approved, SCAODo not write below this line - For court use onlySTATE OF MICHIGANPROBATE COURTCOUNTY OF ORDER FOR EXAMINATION/TRANSPORTFILE NO.PCM 209a (2/19) ORDER FOR EXAMINATION/TRANSPORTMCL 330.1435, MCL 330.1436, MCL 330.1437, MCL 330.1438PCS CODE: OET TCS CODE: OETREPORT OF NON-EXECUTION

File No. 
 

The Order for Examination/Transport issued on 

 has not been executed.  The reason the order was

not executed within 10 days after entry is:  

Date

  

 

 

 

 

Date

 

 

     

     

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

Law enforcement agency

Telephone no.

TO THE LAW ENFORCEMENT AGENCY:  Under MCL 330.1436(2), this report must be filed with the court that issued the 
Order for Examination/Transport if the order is not executed within 10 days after entry of the order.

Order for Examination/Transport (2/19)