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STATE OF MICHIGAN

PROBATE COURT
COUNTY

PETITION FOR MENTAL
HEALTH TREATMENT

AMENDED

CASE NO. and JUDGE

Court address

Court telephone no.

In the matter of

Court ORI

First, middle, and last name

Date of birth
Put DOB in Ref. No.

row 1 on MC 97

Driver's license no.
Put DLN in Ref. No.

row 3 on MC 97

Last 4 digits of SSN

Place of birth

Race

Sex

1. I,

Name (type or print)

, an adult

specify whether a relative, neighbor, peace officer, etc.

petition because

I believe the individual named above needs treatment.

2. The individual was born

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

has a permanent residence in

County at

Street address City, state, zip

and can presently be found at

Facility name or other address

This petition is for a person who was found not guilty by reason of insanity in this county (NGRI).

3. I believe the individual has mental illness and

a. as a result of that mental illness, the individual 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
threats that are substantially supportive of this expectation.

b. as a result of that mental illness, the individual 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. the individual's 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.

4. The conclusions stated above are based on
a. my personal observation of the person doing the following acts and saying the following things:

b. the following conduct and statements that others have seen or heard and have told me about:

by:

Witness name Complete address Telephone no.

Approved, SCAO
Form PCM 201, Rev. 5/22
MCL 330.1100a, MCL 330.1401, MCL 330.1423, MCL 330.1427,
MCL 330.1434, MCL 330.1438, MCL 330.2050, MCR 5.125(C)(18)
Page 1 of 2

PCS Code: PFH/PAS/APMTCS Code: IPFH/PFH/PAS/APM XXX-XX-Put last 4 digits of SSN in Ref. No. row 2 on MC 97.Petition for Mental Health Treatment
Page 2 of 2

(5/22)

5. The persons interested in these proceedings are:

Case No.

NAME

ADDRESS

TELEPHONE

RELATIONSHIP
Spouse

Guardian*

*(Specify the county where the guardianship was established and the case number.)

6. The individual

is not

a veteran.

7. Attached is a

clinical certificate by a physician or licensed psychologist taken within the last 72 hours.
clinical certificate by a psychiatrist taken within the last 72 hours.
no clinical certificate is attached because only assisted outpatient treatment is requested.

8. (For hospitalization and combined treatment only.) An examination could not be secured because:

a. the individual be examined at

the preadmission screening unit or hospital designated by the community mental health services program.

b. a peace officer take the individual into protective custody and transport the individual to

9. I request the court to determine the individual to be a person requiring treatment and to order:

a. hospitalization only.
b. a combination of hospitalization and assisted outpatient treatment.
c. assisted outpatient treatment without hospitalization.

10. I request the individual be hospitalized pending a hearing.

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.

Name (type or print)

Bar no.

Signature of petitioner

Date

Address

Telephone no.

City, state, zip

Home telephone no.

Work telephone no.

This petition for mental health treatment was received by the hospital on

Date

Time

Signature of hospital representative

I request:

Signature of attorney

Address

ity, state, zip

FOR
HOSPITAL
USE ONLY

PCM 201, Petition for Mental Health Treatment

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): 70
Average fields per page: 35
Reading Level: Grade 10
LIST Grouping(s): HE-00-00-00-00, HE-03-00-00-00.

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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.

amended was AMENDED (0.58 conf)
matter was In the matter of (0.33 conf)
court_ori was Court ORI (0.49 conf)
place_birth was Place of birth (0.37 conf)
race was Race (0.41 conf)
sex was Sex (0.38 conf)
1_i was 1 I (0.32 conf)
adult was an adult (0.48 conf)
permanent_residence was has a permanent residence in (0.33 conf)
county__1 was County at (0.29 conf)
presently_found was and can presently be found at (0.37 conf)
petition_person_guilty_reason was This petition is for a person who was found not guilty by reason of insanity in this county NGRI (0.45 conf)
expected_within_near was a as a result of that mental illness the individual can reasonably be expected within the near future to intentionally or (0.33 conf)
individual_unable_physical_must was b as a result of that mental illness the individual is unable to attend to those basic physical needs that must be (0.35 conf)
illness_lack_understanding was c the individuals judgment is so impaired by that mental illness and whose lack of understanding of the need for treatment (0.39 conf)
person_saying_things__1 was a my personal observation of the person doing the following acts and saying the following things 1 (0.42 conf)
person_saying_things__2 was a my personal observation of the person doing the following acts and saying the following things 2 (0.42 conf)
statements_others_seen_heard_told__1 was b the following conduct and statements that others have seen or heard and have told me about 1 (0.41 conf)
statements_others_seen_heard_told__2 was b the following conduct and statements that others have seen or heard and have told me about 2 (0.41 conf)
by was by (0.38 conf)
judge was Judge (0.39 conf)
court_address was Court address (0.42 conf)
court_telephone was Court telephone no (0.51 conf)
text__1 was Text3 (0.35 conf)
text__2 was Text4 (0.35 conf)
county__2 was County (0.39 conf)
name_row__1 was NAMERow1 (0.43 conf)
address_spouse was ADDRESSSpouse (0.40 conf)
telephone_spouse was TELEPHONESpouse (0.43 conf)
name_row__2 was NAMERow2 (0.43 conf)
address_guardian was ADDRESSGuardian (0.42 conf)
telephone_guardian was TELEPHONEGuardian (0.47 conf)
name_row__3 was NAMERow3 (0.43 conf)
guardian_row was GuardianRow1 (0.44 conf)
address_row was ADDRESSRow3 (0.36 conf)
telephone_row was TELEPHONERow3 (0.45 conf)
specify_guardianship_number was Specify the county where the guardianship was established and the case number (0.36 conf)
is was is (0.32 conf)
is_not was is not (0.34 conf)
attached was 7 Attached is a (0.37 conf)
hospitalization_combined_treatment was 8 For hospitalization and combined treatment only An examination could not be secured because (0.36 conf)
clinical_taken_within was clinical certificate by a physician or licensed psychologist taken within the last 72 hours (0.37 conf)
taken_within_last was clinical certificate by a psychiatrist taken within the last 72 hours (0.40 conf)
clinical_outpatient_requested was no clinical certificate is attached because only assisted outpatient treatment is requested (0.37 conf)
undefined__1 was undefined (0.38 conf)
screening_health_program was the preadmission screening unit or hospital designated by the community mental health services program (0.41 conf)
individual_examined was a the individual be examined at (0.44 conf)
officer_individual_custody was b a peace officer take the individual into protective custody and transport the individual to (0.39 conf)
undefined__2 was undefined_2 (0.39 conf)
undefined__3 was undefined_3 (0.39 conf)
hospitalization was a hospitalization only (0.30 conf)
hospitalization_outpatient_treatment was b a combination of hospitalization and assisted outpatient treatment (0.35 conf)
treatment_without_hospitalization was c assisted outpatient treatment without hospitalization (0.34 conf)
request_individual_pending was 10 I request the individual be hospitalized pending a hearing (0.37 conf)
signature_date__1 was Date (1.00 conf)
name_type_print was Name type or print (0.45 conf)
bar was Bar no (0.41 conf)
users1_address_line_one was Address (1.00 conf)
address was Address_2 (0.35 conf)
users1_address_line_two was City state zip (1.00 conf)
telephone was Telephone no (0.44 conf)
city_state_zip was City state zip_2 (0.35 conf)
home_telephone was Home telephone no (0.43 conf)
work_telephone was Work telephone no (0.51 conf)
signature_date__2 was Date_2 (1.00 conf)
time was Time (0.45 conf)
text__3 was Text5 (0.35 conf)
text__4 was Text6 (0.35 conf)
text__5 was Text7 (0.35 conf)
text__6 was Text8 (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 201, Petition for Mental Health Treatment

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Identified Data Fields:

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