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Here is the text we could read:

STATE OF MICHIGAN

CASE NO. and JUDGE

PROBATE COURT
COUNTY

PETITION FOR CONTINUED
HOSPITALIZATION OF MINOR

Court address

Court telephone no.

In the matter of

First, middle, and last name

1. I,

Name (type or print)

Name of hospital

2. On

Date

, am the director or authorized representative of the director

the hospital received a written notice of intent to terminate the hospitalization of the minor from:

the persona in loco parentis

the minor who is 14 years of age or older

the parent

and who was admitted by his or her own request.

the guardian

3. The minor is a resident of

and has parents, guardian, or persona in loco parentis as follows:

, Michigan, was born on

Put DOB in Ref. No.
row 1 on MC 97.
Date of birth

NAME

RELATIONSHIP

ADDRESS

TELEPHONE

Parent

Guardian

Person in loco
parentis

4. An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor

has been previously filed in

assigned to Judge

Court, Case Number

, was

, and

remains

is no longer

pending.

5. The minor is suitable for hospitalization because the minor requires treatment, is in need of hospitalization and is
expected to benefit from hospitalization, and an appropriate, less restrictive alternative to hospitalization is not available.

6. The minor requires treatment because:

of a substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize reality,

or ability to cope with the ordinary demands of life.

of a severe or persistent emotional condition characterized by seriously impaired and personality development,

individual adjustment, social adjustment, or emotional growth, which is demonstrated in behavior symptomatic of that
impairment.

Approved, SCAO
Form PCM 237, Rev. 5/21
MCL 330.1498o
Page 1 of 2

JIS Code: CHMPetition for Continued Hospitalization of Minor
Page 2 of 2

(5/21)

Case No.

7. This conclusion is based upon:

8. The minor will benefit from hospitalization as follows:

9. I request that the minor be determined suitable for hospitalization and ordered to continue hospitalization for not more

than 60 days.

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

physician.
licensed psychologist.

Signature of petitioner

Title of petitioner

This petition is accompanied by one certificate executed by a child and adolescent psychiatrist and one certificate of a

PCM 237, Petition for Continued Hospitalization of Minor

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

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): 46
Average fields per page: 23
Reading Level: Grade 11
LIST Grouping(s): Unknown

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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)
date_personal_information_form was NOTE Provide the date of birth of the minor on a personal identifying information form MC 97 (0.45 conf)
name_type_print was Name type or print (0.45 conf)
name_hospital was Name of hospital (0.35 conf)
parent was the parent (0.45 conf)
guardian was the guardian (0.41 conf)
persona_loco_parentis was the persona in loco parentis (0.39 conf)
minor_years_age_older was the minor who is 14 years of age or older (0.34 conf)
admitted_request was and who was admitted by his or her own request (0.42 conf)
name_row__1 was NAMERow1 (0.43 conf)
address_parent__1 was ADDRESSParent (0.40 conf)
telephone_parent__1 was TELEPHONEParent (0.43 conf)
name_row__2 was NAMERow2 (0.43 conf)
address_parent__2 was ADDRESSParent_2 (0.39 conf)
telephone_parent__2 was TELEPHONEParent_2 (0.42 conf)
name_row__3 was NAMERow3 (0.43 conf)
address_guardian was ADDRESSGuardian (0.42 conf)
telephone_guardian was TELEPHONEGuardian (0.47 conf)
name_row__4 was NAMERow4 (0.43 conf)
address_person_loco_parentis was ADDRESSPerson in loco parentis (0.37 conf)
telephone_person_loco_parentis was TELEPHONEPerson in loco parentis (0.43 conf)
action_division_involving was 4 An action within the jurisdiction of the family division of circuit court involving the family or family members of the minor (0.37 conf)
court_case_number was Court Case Number (0.46 conf)
previously_filed was has been previously filed in (0.40 conf)
remains was remains (0.32 conf)
longer was is no longer (0.37 conf)
thought_significantly_recognize was of a substantial disorder of thought or mood that significantly impairs judgment behavior capacity to recognize reality (0.35 conf)
persistent_condition was of a severe or persistent emotional condition characterized by seriously impaired and personality development (0.34 conf)
judge was Judge (0.39 conf)
text__1 was Text2 (0.35 conf)
was was was (0.41 conf)
undefined__1 was undefined (0.38 conf)
conclusion_based_upon__1 was 7 This conclusion is based upon 1 (0.38 conf)
conclusion_based_upon__2 was 7 This conclusion is based upon 2 (0.38 conf)
conclusion_based_upon__3 was 7 This conclusion is based upon 3 (0.38 conf)
minor_benefit_follows__1 was 8 The minor will benefit from hospitalization as follows 1 (0.34 conf)
minor_benefit_follows__2 was 8 The minor will benefit from hospitalization as follows 2 (0.34 conf)
minor_benefit_follows__3 was 8 The minor will benefit from hospitalization as follows 3 (0.34 conf)
minor_benefit_follows__4 was 8 The minor will benefit from hospitalization as follows 4 (0.34 conf)
information_knowledge_belief was best of my information knowledge and belief (0.25 conf)
undefined__2 was undefined_2 (0.39 conf)
accompanied_one_child was This petition is accompanied by one certificate executed by a child and adolescent psychiatrist and one certificate of a (0.40 conf)
undefined__3 was undefined_3 (0.39 conf)
text__2 was Text3 (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 237, Petition for Continued Hospitalization of Minor

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