Approved, SCAO

STATE OF MICHIGAN

JUDICIAL CIRCUIT COURT
COUNTY

In the matter of

APPEAL OF COMMITMENT AND
ORDER TO RECONVENE
COMMITMENT REVIEW PANEL

CASE NO.

1. I was committed to and am presently in

as ordered by the court on

Date

2. I claim an appeal of my commitment.

CLAIM OF APPEAL

Name of facility

     .

I REQUEST  that the court reconvene my commitment review panel for a recommendation as to whether my commitment should
be terminated.  I understand that the court will reconvene the commitment review panel as soon as possible, but not more than
14 days after I have filed this claim of appeal.

Date

Signature

1. Date of Hearing:

IT IS ORDERED:

Name

2. The previously appointed commitment review panel consisting of

ORDER

Judge:

Name

, and

Name

shall reconvene and report to the court in writing within 14 days of the date of this order.

3. The panel shall do the following:

a. Review the appeal and any other information considered relevant by the commitment review panel.

b. Interview the individual, or document the reasons why the individual was not interviewed.

c. Recommend to the circuit court either termination or continuation of the commitment and document the reasons for the

recommendation.

Date

Judge

Do not write below this line - For court use only

    ,

Bar no.

    ,

PC 113   (6/98)   APPEAL OF COMMITMENT AND ORDER TO RECONVENE COMMITMENT REVIEW PANEL

MCL 333.5205(10); MSA 14.15(5205(10), MCR 5.782



Appeal of Commitment and Order to Reconvene Commitment Review Panel

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• Sourced from www.courts.michigan.gov/commitment-testing-ID (2023-03)
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• Fields(s): 7
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