In the matter of 

First, middle, and last name

1. Date of hearing (if one): 
 

  Judge: 

   

 

Bar no.

2. This court issued an 

 

  initial 

 

  second 

 

  continuing 

  order on 

 directing the individual 

Date

  named above to undergo a program of assisted outpatient treatment or combined hospitalization and assisted 
  outpatient treatment.

 the individual is not complying with the order for assisted outpatient treatment or combined hospitalization and assisted 

 assisted outpatient treatment has not been or will not be sufficient to prevent harm the individual may inflict upon 

 the individual believes that the assisted outpatient treatment program is not appropriate.

    outpatient treatment.

3. The court has been notified that
 
 
 
 
 

    self or others.

4. THE COURT FINDS:
 

IT IS ORDERED:

 

 

 

 

 

 
 
 

 
 
 
 

 5.  The order for assisted outpatient treatment or combined hospitalization and assisted outpatient treatment is modified and 
    the individual shall undergo a program of assisted outpatient treatment as ordered in item 8 below. This assisted 
    outpatient treatment shall not exceed the time from the date of issuance of the
   

  combined order.

 continuing  

  initial 
 
 
 

 second 

 

 

 
 
  

 6.  The order for assisted outpatient treatment or combined hospitalization and assisted outpatient treatment is modified and 
    the individual shall be hospitalized at 
    for a period not to exceed the remainder of the previously-ordered hospitalization portion of the 
   

  combined order.

 continuing  

 second 

 initial 

 

 

 

 7. The order for assisted outpatient treatment or combined hospitalization and assisted outpatient treatment is modified and 
    the individual shall continue to undergo combined hospitalization and assisted outpatient treatment as ordered in item 8 
    below for the remainder of the previously-ordered period.  The individual shall be hospitalized at 
   
    hospitalization portion of the 

 for a period not to exceed the remainder of the initially ordered 

  combined order.    

 continuing 

  second 

  initial 

 

 

 

 

Approved, SCAODo not write below this line - For court use only(SEE SECOND PAGE)USE NOTE:  Use form PCM 244 to modify an order for assisted outpatient treatment or an order for combined hospitalization and assisted outpatient treatment under MCL 330.1475(3)-(5).STATE OF MICHIGANPROBATE COURTCOUNTY OF ORDER TO MODIFY ORDER FOR ASSISTED OUTPATIENT TREATMENT OR COMBINED HOSPITALIZATION AND ASSISTED OUTPATIENT TREATMENTFILE NO.PCM 217a (12/19) ORDER TO MODIFY ORDER FOR ASSISTED OUTPATIENT TREATMENT       OR COMBINED HOSPITALIZATION AND ASSISTED OUTPATIENT TREATMENTMCL 330.1475(1), (2), MCR 5.744PCS CODE: C9MTCS CODE: C9M                                  

 
8.   Assisted outpatient treatment services shall be supervised by

 

 

Community mental health services or other designated entity

File No. 
 

 .

 case management plan 
 
 case management services
 all services recommended by the treatment provider
 medication
 blood or urinalysis tests to determine compliance with or effectiveness of prescribed medication
 individual therapy 
 day programs 
 educational training 
 supervised living
 assertive community treatment team services
 substance use disorder treatment
 substance use disorder testing (for individuals with a history of alcohol or substance use and for whom testing is 

  The following assisted outpatient services are ordered:
 
 
 
 
 
 
 
 
 
 
 
 
      necessary to assist the court in ordering treatment designed to prevent deterioration)
 
 any other services prescribed to treat the individual’s mental illness and either to assist the individual in living and 
      functioning in the community or to help prevent a relapse or deterioration that may reasonably be predicted to result in

 
 group therapy 
 
 partial day programs

 individual and group therapy

 vocational training

 

 

      suicide or the need for hospitalization. Those services are:  
 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

   

   

 

   

   

   

 

 

NOTICE: The court must be promptly notified of the individual’s release from the hospital to the assisted outpatient treatment 

  program, along with a psychiatrist’s statement that the individual is clinically appropriate for assisted outpatient treatment. 

 9. If the individual refuses to comply with a psychiatrist’s order to return to the hospital, a peace officer shall take the 
    individual into protective custody and transport the individual to the hospital designated by the psychiatrist.  
     

 
 
10.  This order expires on 

 . 

Date

 

Date

Judge

NOTICE OF RIGHT TO OBJECT TO HOSPITALIZATION

If the court has ordered you to be hospitalized rather than continue in an assisted outpatient treatment program 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. 

I certify that this notice was personally served on the individual named above on 

Date

 at 

Time

 Court on 

Date

 

 .

and a copy was mailed to the 

 

 

                     

I object to my hospitalization and request that the court schedule a hearing on the objection.

OBJECTION TO HOSPITALIZATION

PROOF OF SERVICE

 

 

Signature

Signature

Date

 

Order to Modify Order for Assisted Outpatient Treatment or Combined Hospitalization and Assisted Outpatient Treatment (12/19)