. 

 .

In the matter of 

First, middle, and last name

1. I, 

Name (type or print)

  of involuntary mental health treatment and I am

 , state that the individual is subject to a one-year order 

 the executive director of the community mental health services program for the county of residence of the individual.

 hospitalized in 

Name of hospital

 under a one-year assisted outpatient or a one-year combined treatment order under the supervision of

 

 

 

   

 

   

 

 2. I object to the conclusion(s) in the periodic review report of 
 
  dated 
 
  a person requiring continuing involuntary mental health treatment and should be discharged from the program.
 

 
 
 
 
 
3. The interested parties, their addresses, and their representatives are identical to those appearing on the initial petition,  
  except as follows: 

 and filed with this court. The individual named in that report is not  

Name of patient/resident

 

4. I REQUEST that the court set a hearing and order a discharge.

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

 

Signature of petitioner

Approved, SCAODo not write below this line - For court use onlyUSE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.STATE OF MICHIGANPROBATE COURTCOUNTY OF PETITION FOR DISCHARGE FROM CONTINUING MENTAL HEALTH TREATMENTFILE NO.PCM 220 (2/19) PETITION FOR DISCHARGE FROM CONTINUING MENTAL HEALTH TREATMENTMCL 330.1483, MCL 330.1484PCS CODE: DIPTCS CODE: DIP