Petition For Second Or Continuing Treatment Order {PCM 218}

In the matter of First, middle, and last name þ DOB: þ STATE OF MICHIGANPROBATE COURTCOUNTY OF PETITION FOR SECOND þ CONTINUINGMENTAL HEALTH TREATMENT ORDERFILE NO. en-US1. I, en-USName (type or print)en-US, state that I am þ þ the authorized representative of the agency or mental health professional supervising the individual222s assisted þ outpatient treatment program. þ þ þ en-USDirector or authorized representativeen-US of en-USName of hospital . þ þ þ 2. þ The individual is currently þ þ residing þ þ hospitalized þ at en-USAddress and telephone no.en-US þ þ en-US . þ þ þ 3. þ The þ þ initial þ þ second þ þ continuing þ order entered by this court for the individual expires on en-USDateen-US . 4. þ The individual continues to be a person requiring treatment and is in need of þ þ hospitalization for not more than 90 days. þ þ continuing hospitalization for a period of one year. þ þ combined hospitalization and assisted outpatient treatment for not more than one year. þ þ assisted outpatient treatment for not more than one year. 5. þ The individual is likely to refuse treatment on a voluntary basis when the order expires. en-USINSTRUCTIONS: In answering items 6 and 7, include a description of the observed or reported behavior of the individual en-USincluding, but not limited to, how behavior and conditions have changed since the last order and whether any stabilization or en-USremission is contingent on continued medication or other treatment. Avoid medical terms and conclusions other than diagnosis. 6. þ The basis for this allegation is that I believe the individual has a mental illness and: en-US(Check all that apply.) þ þ a. þ as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ that are substantially supportive of this expectation. þ b. þ as a result of that mental illness, the individual is unable to attend to those basic physical needs that must be attended þ to in order to avoid serious harm in the near future, and has demonstrated that inability by failing to attend to those basic þ physical needs. þ c. þ the individual222s judgment is so impaired by that mental illness and whose lack of understanding of the need for þ treatment has caused him or her to demonstrate an unwillingness to voluntarily participate in or adhere to þ treatment that is necessary, on the basis of competent clinical opinion, to prevent a relapse or harmful deterioration þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ 7. þ This conclusion is based upon þ a. my personal observation of the person doing the following acts and saying the following things: þ þ en-US þ en-US þ þ American LegalNet, Inc. www.FormsWorkFlow.com File No. þ b. the following conduct and statements that others have seen or heard and have told me about: þ þ en-US þ þ en-US þ þ by: Witness name þ Complete address þ þ Telephone no. 8. þ The diagnoses of physical and mental conditions are en-US þ en-US en-US . þ 9. þ The treatment program(s) provided to the individual thus far, and the results, are en-US þ þ en-US þ en-US þ en-US en-US . þ 10. þ The present treatment þ þ is þ þ is not þ adequate and appropriate to the individual's condition. þ The individual þ þ is þ þ is not þ motivated to participate in this treatment program. The estimate of further time necessary þ þ to provide the required treatment is en-US en-US . þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-US þ þ en-US 11. þ The interested parties, their addresses, and their representatives are identical to those appearing on the initial petition þ except as follows: þ þ þ þ þ þ þ þ 13. þ en-USI REQUESTen-US the court to order the individual to receive þ þ hospitalization for not more than 90 days. þ þ continuing hospitalization for not more than one year. þ þ combined hospitalization and assisted outpatient treatment for not more than þ 90 days þ en-US one year. þ þ assisted outpatient treatment for not more than þ 90 days þ en-US one year.en-USI declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of en-USmy information, knowledge, and belief. en-USDate þ en-USSignature of petitioner þ þ en-USAddress þ þ City, state, zipþ Telephone no. American LegalNet, Inc. www.FormsWorkFlow.com