STATE OF MICHIGAN

CASE NO. and JUDGE

PROBATE COURT
COUNTY

SECOND ORDER 
FOR MENTAL HEALTH TREATMENT

Court address              

 

 

 

Court telephone no.

In the matter of 

First, middle, and last name

      

Last 4 digits of SSN

 asserting that the individual named

1.	A	petition	has	been	filed	by	

Petitioner	name	(type	or	print)

  above is a person requiring treatment.

THE COURT FINDS:
2. Notice of hearing has been given according to law.
 
3. The individual 
  The hearing was 

  was present in court. 
  with 

	 without		 a	jury.

 

 

 

  was not present for reasons stated on the record. 

  Present were: 

 

	,	attorney	for	the	individual,	and

 

 

 

 

 

 
	4.	Testimony	of	a	physician,	psychiatrist,	or	licensed	psychologist	was	waived	by	the	individual	and	the	individual's	
	 attorney.

	,	attorney	for	the	petitioner.	

 

5. 
 

	Testimony	was	given	by	
 
	Testimony	was	not	given	because	the	parties	stipulated	to	entry	of	the	order.

 .

	
	

	
	

threats	that	are	substantially	supportive	of	this	expectation.

	a.	and	as	a	result	of	that	mental	illness	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			
	
	b.	and	as	a	result	of	that	mental	illness	is	unable	to	attend	to	those	basic	physical	needs	that	must	be	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.	 whose	judgment	is	so	impaired	by	that	mental	illness,	and	whose	lack	of	understanding	of	the	need	for	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.

	6.	By	clear	and	convincing	evidence,	the	individual	continues	to	be	a	person	requiring	treatment	because	the	individual	has
  a mental illness, 
 
	
	
 
	
	
 
	
	
	
 7. There 
	
	
  professional available to supervise the individual’s treatment program.

  is not  an available treatment program that is an alternative to hospitalization or that follows an 
initial	period	of	hospitalization	adequate	to	meet	the	individual's	treatment	needs,	is	sufficient	to	prevent	harm	that
the	individual	may	inflict	upon	self	or	others	within	the	near	future,	and	there	is	an	agency	or	mental	health

  is 

	
	
	

 

	

 
 
	
	
 
	
	
 
	
	
	

	
	
 

Approved, SCAO
Form PCM 219, Rev. 5/22
MCL 330.1401, MCL 330.1464a, MCL 330.1468, MCL 330.1469a, 
MCL 330.1470, MCL 330.1472a(2)
Page 1 of 3

Court ORIDate of birthDriver’s license no.Place of birthRaceSexCurrent address of individualPCS Code: SOTTCS Code: SORDXXX-XX-Second Order for Mental Health Treatment 
Page 2 of 3

(5/22) 

Case No. 
 

 hospital can provide treatment

 8. 
 

 

 
that is adequate and appropriate to the individual’s condition.

 9. The individual is not a person requiring treatment.

IT IS ORDERED:

	10.	 The	individual	shall	be	hospitalized	for	up	to	90	days.

	11.	 The	individual	shall	receive	combined	hospitalization	and	assisted	outpatient	treatment	for	no	longer	than	90	days.
      The individual shall be hospitalized for up to 
     
   
	12.	 The	individual	shall	receive	assisted	outpatient	treatment	for	no	longer	than	90	days.

	days	of	the	assisted	outpatient	treatment	period.

 An initial hospitalization period shall be up to 

	days.

 

 

13.	 Any	hospitalization	of	the	individual	for	mental	health	treatment	shall	occur	in	the	hospital	listed	in	item	8.

14.	 Any	assisted	outpatient	treatment	services	shall	be	supervised	by

 

Community	mental	health	services	or	other	designated	entity	

	
	group	therapy	
	
	partial	day	programs

 case management plan
 case management services
	all	services	recommended	by	the	treatment	provider
 medication
	blood	or	urinalysis	tests	to	determine	compliance	with	or	effectiveness	of	prescribed	medication
	individual	therapy	
	day	programs	
 educational training 
 supervised living
	assertive	community	treatment	team	services
 substance use disorder treatment
	substance	use	disorder	testing	(for	individuals	with	a	history	of	alcohol	or	substance	use	and	for	whom	testing	is	

  The following assisted outpatient services are ordered:
 
 
 
 
 
 
 
 
 
 
 
 
	 	 	 necessary	to	assist	the	court	in	ordering	treatment	designated	to	prevent	deterioration)
 
	any	other	services	prescribed	to	treat	the	individual’s	mental	illness	and	either	to	assist	the	individual	in	living	and	
	 	 	 functioning	in	the	community	or	to	help	prevent	a	relapse	or	deterioration	that	may	reasonably	be	predicted	to	result	
      in suicide or the need for hospitalization. Those services are: 

	individual	and	group	therapy

 vocational training

 

	

 

 .

 

 15.  The petition is 

 

  denied on the merits. 

 

  dismissed. 

 

  withdrawn.

	16.	 If	the	individual	refuses	to	comply	with	a	psychiatrist's	order	for	hospitalization,	a	peace	officer	shall	take	the	individual
	 	 	 into	protective	custody	and	transport	the	individual	to	the	hospital	designated	by	the	psychiatrist.

17.	 If	item	10	or	11	is	checked,	the	Michigan	State	Police	shall	immediately	enter	the	individual’s	identifying	information	
 

  in this court order on LEIN.

 
 
 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
	
 
	
 

 

 
 

	

     

     

 

 

Second Order for Mental Health Treatment 
Page 3 of 3

(5/22) 

Case No. 
 

18.	 If	felony	charges	have	been	previously	dismissed	under	MCL	330.2044(1)(b)	and	the	time	for	petitioning	to	refile		
	

	 charges	has	not	elapsed,	not	less	than	30	days	before	the	scheduled	release	or	discharge:

	

	
	

	
	
	
 

	 a.	the	director	of	the	treating	facility	shall	notify	the	prosecutor's	office	in	the	county	in	which	charges	against	the	person	
	 	 	 were	originally	brought	that	the	patient's	release	or	discharge	is	pending.

	 b.	the	patient	to	be	released	or	discharged	shall	undergo	a	competency	examination	as	described	in	MCL	330.2026.			
	 	 	 A	copy	of	the	written	report	of	the	examination	along	with	the	notice	required	in	item	18a	above	shall	be	submitted			
	 	 	 to	the	prosecutor's	office	in	the	county	in	which	the	charges	against	the	patient	were	originally	brought.	The	written		
      report is admissible as provided in MCL 330.2030(3).

 

 

 

 

 

 

                                                                                         Judge signature and date