In the matter of 

First, middle, and last name

1. Date of hearing (if one): 
 

2. This court issued an order on 

Date

 

  Judge: 

 directing the individual named above to undergo a program of 

Bar no.

  assisted outpatient treatment or combined hospitalization and assisted outpatient treatment.
3.	The	court	has	been	notified	that	the	individual	is	not	complying	with	the	order	for	assisted	outpatient	treatment	or	combined
  hospitalization and assisted outpatient treatment.
4. THE COURT FINDS:

 

IT IS ORDERED:

 

 

	
 

	the	preadmission	screening	unit	established	by	the	community	mental	health	services	program	serving	the	community	
in	which	the	individual	resides.	
 
 

	5.	A	peace	officer	shall	take	the	individual	into	protective	custody	and	transport	the	individual	to
 
	
 
 6. The individual shall be hospitalized at 
	
	
	for	a	period	of	not	more	than	10	days.	If	necessary,	a	peace	officer	shall	take	the	individual	into	protective	custody.	
 
	as	recommended	by	the	community	mental	health	services	program,	more	than	10	days	but	not	longer	than	the	duration	
 
  of the order for assisted outpatient treatment or a combination of hospitalization and assisted outpatient treatment, or 
 
	
	 not	longer	than	90	days,	whichever	is	less.	If	necessary,	a	peace	officer	shall	take	the	individual	into	protective	custody.
	7.	The	individual	may	return	to	assisted	outpatient	treatment	before	the	expiration	of	the	prior	order	of	assisted	outpatient		
	

treatment	or	combined	hospitalization	and	assisted	outpatient	treatment	as	follows:

Designated	facility

 

   

 
	
 

 
 
 
	

	

Date

Judge

NOTICE OF RIGHT TO OBJECT TO HOSPITALIZATION

If	the	court	ordered,	without	a	hearing,	that	you	be	hospitalized,	you	have	a	right	to	object	to	this	hospitalization.	If	you	wish	to	
object,	complete	the	objection	below	and	send	a	copy	to	the	court	within	7	days	of	receiving	this	notice.

PROOF OF SERVICE

    

I	certify	that	this	notice	was	personally	served	on	the	above	individual	on	
 
and	a	copy	mailed	to	the	
 

Date

 at 

Time

 Court on 

Date

 

 .

 

 

 

 

 

 

 

Date

OBJECTION TO HOSPITALIZATION

Signature

 

Signature

I	object	to	my	hospitalization	and	request	that	the	court	schedule	a	hearing	on	the	objection	in	accordance	with	MCR	5.744.

 

 

Approved, SCAODo not write below this line - For court use onlySTATE OF MICHIGANPROBATE COURTCOUNTY OF ORDER AFTER NOTICE OF NONCOMPLIANCE WITH ASSISTED OUTPATIENT TREATMENT OR COMBINED HOSPITALIZATION AND ASSISTED OUTPATIENT TREATMENT ORDERFILE NO.PCM 244 (9/16) ORDER AFTER NOTICE OF NONCOMPLIANCE WITH ASSISTED OUTPATIENT TREATMENT OR       COMBINED HOSPITALIZATION AND ASSISTED OUTPATIENT TREATMENT ORDERMCL 330.1475(3), (4), (5), (6), MCR 5.744PCS CODE: OFNTCS CODE: OFN