Order For Placement Of Individual With Developmental Disability {PC 665}

Approved, SCAO OSM CODE: OPI STATE OF MICHIGAN FILE NO. ORDER FOR PLACEMENT OF PROBATE COURT INDIVIDUAL WITH COUNTY DEVELOPMENTAL DISABILITY CIRCUIT COURT - FAMILY DIVISION In the matter of , an individual with a developmental disability1. Date of hearing: Judge: Bar no.2. The guardian has filed a petition requesting authority to execute an app lication for admission of the individual to a facility. THE COURT FINDS: 3. Notice of hearing was given to or waived by all interested persons. 4. is the guardian of the person for the above named individual. Name 5. From testimony given in open court and from the report and evaluation fi led with the court, the individual requires care and services at . Name of facility 6. The placement offers appropriate treatment and residential programs to m eet the individuals need. 7. There appears to be no less restrictive treatment and residential progra m available to meet the individuals needs. IT IS ORDERED: 8. The guardian is authorized to execute the necessary application for the temporary administrative admission not to exceed 30 days administrative admission admission of the above named individual to . Name of facility Date Judge Do not write below this line - For court use only American LegalNet, Inc. www.USCourtForms.com MCL 330.1623; MSA 14.800(623), MCR 5.746(B)PC 665 (9/00) ORDER FOR PLACEMENT OF INDIVIDUAL WITH DEVELOPMENTAL DISABILITY