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Here is the text we could read:

In the matter of

First, middle, and last name

ORDER

IT IS ORDERED that

Name (type or print)

shall prepare a report assessing the current

availability and appropriateness of alternatives to hospitalization for the individual named above including alternatives available
following an initial period of court-ordered hospitalization.

The report shall be made to the court before the hearing on

Date and time of hearing

Petition for 60-day order, discharge, etc.

Date

Judge

for

Bar no.

REPORT ON EVALUATION OF HOSPITAL TREATMENT AND/OR ALTERNATIVE PROGRAMS

1. I,

Name

, as

Profession, organization, and position

, report as follows.

2. I have reviewed, as to their availability in or near the individual’s home community, treatment resources alternative to
hospitalization and report as follows: (If practical, give name of agency, program, etc.)

a. Independent mental health professional:

b. Community mental health day treatment, aftercare service, work activity, or other program:

c. Substance abuse, rehabilitation service, or similar program of public or private agency:

d. Other:

Approved, SCAODo not write below this line - For court use only(SEE SECOND PAGE)STATE OF MICHIGANPROBATE COURTCOUNTY OF ORDER AND REPORT ONALTERNATIVE MENTAL HEALTH TREATMENTFILE NO.PCM 216 (12/19) ORDER AND REPORT ON ALTERNATIVE MENTAL HEALTH TREATMENTMCL 330.1453a, MCL 330.1468, MCR 5.741PCS CODE: ORA/RATTCS CODE: ORA/RAT3. I have reviewed, as to their availability in or near the individual's home community, residential accommodations, and I report
as follows: (If practical, give name of residence, location, etc.)

File No.

a. Independent:

Individual’s own house, apartment, etc.

b. Residence of relative or friend:

c. Foster care home:

d. Nursing home:

e. Other:

4. I recommend release.

5. I recommend a course of treatment of

hospitalization.

hospitalization for

assisted outpatient treatment as follows:

days, followed by assisted outpatient treatment as follows:

6. My recommendation is based upon the following described interviews, observations, and information:

7. The individual

has

does not have

a durable power of attorney or advance directive that direct the following

mental health treatment:

appropriately and adequately because

8. I believe the hospital to which admission is proposed

can

cannot

provide its prescribed treatment program

9. I recommend the following agency or independent mental health professional to supervise the outpatient treatment:

Name

Complete address

The agency or professional

has

has not indicated capability and willingness to supervise the recommended program.

10. The individual currently has the following source(s) of funds to cover his or her care in the community:

Order and Report on Alternative Mental Health Treatment (12/19)File No.

11. The individual does not currently have sufficient sources of funds for community living.

a. Application for supplemental funds has been made. They should be available

b. Application for supplemental funds has not been made because

Application will be made on

and should be available about

c. Pending receipt of supplemental funds, the following funds will be available:

Direct relief.

Date

MDHHS/CMH emergency care funds.

Other assistance:

None. Reason:

Signature

Order and Report on Alternative Mental Health Treatment (12/19)

PCM 216, Order and Report on Alternative Mental Health Treatment

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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): 3
Fields(s): 66
Average fields per page: 22
Reading Level: Grade 13
LIST Grouping(s): HE-03-00-00-00, ES-05-00-00-00, HE-00-00-00-00.

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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.

stat_e_f_n_cour_count was STATE OF MICHIGAN PROBATE COURT COUNTY OF (0.67 conf)
matter was In the matter of (0.33 conf)
ordere was IT IS ORDERED that (0.34 conf)
report_shall_court_hearing__1 was The report shall be made to the court before the hearing on 1 (0.39 conf)
report_shall_court_hearing__2 was The report shall be made to the court before the hearing on 2 (0.39 conf)
signature_date__1 was Date (1.00 conf)
judge was Judge (0.39 conf)
bar was Bar no (0.41 conf)
1_i was 1 I (0.32 conf)
as was as (0.32 conf)
mental_health_professional was a Independent mental health professional (0.35 conf)
health_activity_program was b Community mental health day treatment aftercare service work activity or other program (0.30 conf)
unknown__1 was 1 (0.38 conf)
unknown__2 was 2 (0.38 conf)
unknown__3 was 3 (0.38 conf)
public_private_agency was c Substance abuse rehabilitation service or similar program of public or private agency (0.41 conf)
d_other was d Other (0.33 conf)
1_2 was 1_2 (0.38 conf)
2_2 was 2_2 (0.38 conf)
text__1 was Text1 (0.35 conf)
text__2 was Text2 (0.35 conf)
follows_give_location was as follows If practical give name of residence location etc (0.40 conf)
individuals_house_etc was Individuals own house apartment etc (0.45 conf)
b_residence_relative_friend was b Residence of relative or friend (0.33 conf)
c_foster_care_home was c Foster care home (0.38 conf)
undefined__1 was undefined (0.38 conf)
nursing_home was d Nursing home (0.44 conf)
e was e Other (0.44 conf)
recommend_release was 4 I recommend release (0.37 conf)
recommend_course_treatment was 5 I recommend a course of treatment of (0.35 conf)
hospitalization__1 was hospitalization (0.33 conf)
hospitalization__2 was hospitalization for (0.26 conf)
outpatient_treatment_follows was assisted outpatient treatment as follows (0.37 conf)
followed_outpatient_treatment was days followed by assisted outpatient treatment as follows (0.35 conf)
1_3 was 1_3 (0.38 conf)
2_3 was 2_3 (0.38 conf)
following_observations_information__1 was 6 My recommendation is based upon the following described interviews observations and information 1 (0.31 conf)
following_observations_information__2 was 6 My recommendation is based upon the following described interviews observations and information 2 (0.31 conf)
following_observations_information__3 was 6 My recommendation is based upon the following described interviews observations and information 3 (0.31 conf)
following_observations_information__4 was 6 My recommendation is based upon the following described interviews observations and information 4 (0.31 conf)
has was has (0.36 conf)
does_not_have was does not have (0.45 conf)
power_direct_following was a durable power of attorney or advance directive that direct the following (0.34 conf)
mental_health_treatment was mental health treatment (0.33 conf)
can was can (0.39 conf)
cannot was cannot (0.42 conf)
believe_admission_proposed was 8 I believe the hospital to which admission is proposed (0.44 conf)
appropriately_adequately was appropriately and adequately because (0.44 conf)
following_agency_mental was 9 I recommend the following agency or independent mental health professional to supervise the outpatient treatment (0.35 conf)
has_2 was has_2 (0.36 conf)
recommended_program was has not indicated capability and willingness to supervise the recommended program (0.36 conf)
unknown__4 was 10 (0.38 conf)
individual_sufficient_community was 11 The individual does not currently have sufficient sources of funds for community living (0.41 conf)
undefined__2 was undefined_2 (0.39 conf)
funds_made_available was a Application for supplemental funds has been made They should be available (0.42 conf)
application_funds_made was b Application for supplemental funds has not been made because (0.41 conf)
undefined__3 was undefined_3 (0.39 conf)
application_made was Application will be made on (0.34 conf)
available was and should be available about (0.36 conf)
direct_relief was Direct relief (0.42 conf)
mdhhscm_h_emergency_care_funds was MDHHSCMH emergency care funds (0.37 conf)
assistance was Other assistance (0.38 conf)
none_reason was None Reason (0.37 conf)
undefined__4 was undefined_4 (0.39 conf)
undefined__5 was undefined_5 (0.39 conf)
signature_date__2 was Date_2 (1.00 conf)
text__3 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 216, Order and Report on Alternative Mental Health Treatment

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