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STATE OF MICHIGAN
PROBATE COURT
COUNTY
INITIAL ORDER AFTER HEARING
ON PETITION FOR MENTAL
HEALTH TREATMENT
CASE NO. and JUDGE
Court address
Court telephone no.
In the matter of
First, middle, and last name
Last 4 digits of SSN
asserting that the individual named
1. A petition has been filed by
Petitioner name (type or print)
above is a person requiring treatment.
THE COURT FINDS:
2. Notice of hearing has been given according to law.
3. The individual
The hearing was
was present in court.
with
without
a jury.
Present were:
was not present for reasons stated on the record.
, attorney for the individual, and
, attorney for the petitioner.
4. Testimony of a physician, psychiatrist, or licensed psychologist was waived by the individual and the individual’s
attorney.
5.
Testimony was given by
Testimony was not given because the parties stipulated to entry of the order.
.
6. By clear and convincing evidence, the individual is a person requiring treatment because the individual has a mental
illness,
b. and as a result of that mental illness is unable to attend to those basic physical needs that must be attended to
a. and as a result of that mental illness 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.
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. whose 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.
Approved, SCAO
Form PCM 214, Rev. 5/22
MCL 330.1401, MCL 330.1464a, MCL 330.1465, MCL 330.1468,
MCL 330.1469a, MCL 330.1470, MCL 330.1472a(1)
Page 1 of 3
Court ORIDate of BirthDriver’s license no.Place of birthRaceSexCurrent address of individualPCS Code: OHA/OAOTCS Code: OFH/OAOXXX-XX- Initial Order After Hearing on Petiton for Mental Health Treatment
Page 2 of 3
(5/22)
Case No.
7. There
prevent harm that the individual may inflict upon self or others within the near future.
follows an initial period of hospitalization adequate to meet the individual’s treatment needs and is sufficient to
is not an available treatment program that is an alternative to hospitalization or that
is
8.
which is adequate and appropriate to the individual’s condition.
hospital can provide treatment,
9. The individual is not a person requiring treatment.
IT IS ORDERED:
10. The individual shall be hospitalized for up to 60 days with no assisted outpatient treatment.
11. The individual shall receive combined hospitalization and assisted outpatient treatment for no longer than 180 days.
The individual shall be hospitalized for up to 60 days of the 180-day assisted outpatient treatment period.
An initial hospitalization period shall be up to
12. The individual shall receive assisted outpatient treatment for no longer than 180 days.
1 to 60 days
days.
13. Any hospitalization of the individual for mental health treatment shall occur in the hospital listed in item 8.
14. Any assisted outpatient treatment services shall be supervised by
Community mental health services or other designated entity
.
group terapy
partial day programs
case managment plan
case managment 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 designated 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 suicide or the need for hospitalization. Those services are:
individual and group therapy
vocational training
15. The assisted outpatient treatment plan shall be completed within 30 days after entry of the court’s order of assisted
outpatient treatment and a copy shall be forwarded to the probate court for filing within 3 days after completion of the
plan to be maintained in the court file.
Initial Order After Hearing on Petiton for Mental Health Treatment
Page 3 of 3
(5/22)
Case No.
16. If the individual refuses to comply with a psychiatrist’s order for hospitalization, a peace officer shall take the individual
into protective custody and transport the individual to the hospital designated by the psychiatrist.
17. If item 10 or 11 is checked, the Michigan State Police shall immediately enter the individual’s identifying information
in this court order on LEIN.
18. If felony charges have been previously dismissed under MCL 330.2044(1)(b) and the time for petitioning to refile
charges has not elapsed, not less than 30 days before the scheduled release or discharge:
a. the director of the treating facility shall notify the prosecutor’s office in the county in which charges against the person
were originally brought that the patient’s release or discharge is pending.
b. the patient to be released or discharged shall undergo a competency examination as described in MCL 330.2026.
A copy of the written report of the examination along with the notice required in item 18a above shall be submitted
to the prosecutor’s office in the county in which the charges against the patient were originally brought. The written
report is admissible as provided in MCL 330.2030(3).
19. The petition is
denied on the merits.
dismissed.
withdrawn.
Judge signature and date
PCM 214, Initial Order After Hearing on Petition for Mental Health Treatment
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About This Form:
- Sourced from www.courts.michigan.gov/MH-Forms (2023-03)
- Page(s): 3
- Fields(s): 65
- Average fields per page: 21
- Reading Level: Grade 15
- 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.
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