Pcm 208 - Clinical Certificate - State Of Michigan Probate Court County
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2PCS CODE: CCT
Approved, SCAO
TCS CODE: CCT
STATE OF MICHIGAN
FILE NO.
PROBATE COURT
CLINICAL CERTIFICATE
COUNTY OF
In the matter of
First, middle, and last name
TO THE EXAMINER: The following is a statement that must be read to the individual before proceeding with any questions.
I am authorized by law to examine you for the purpose of advising the court if you have a mental condition
which needs treatment and whether such treatment should take place in a hospital or in some other place.
I am also here to determine if you should be hospitalized or remain hospitalized before a court hearing is
held. I may be required to tell the court what I observe and what you tell me.
1. I am a
psychiatrist.
licensed psychologist.
physician.
2. I certify that on this date I read the above statement to the individual before asking any questions or conducting any examination.
3. I further certify that I,
, personally examined
Name (type or print)
Patient
at
Name and address where examination took place
on
starting at
and continuing for
minutes.
Date
Time
INSTRUCTIONS: Describe in detail the specific actions, statements, demeanor, and appearance of the individual, together
with other information which underlie your conclusion. Indicate the source of any information not personally known or
observed. If this certificate is to accompany a petition for discharge, state why the individual continues to be or is no longer a
person requiring treatment or in need of hospitalization.
4. My determination is that the person is
mentally ill (has a substantial disorder of thought or mood that significantly impairs judgment, behavior, capacity to recognize
reality, or ability to cope with the ordinary demands of life).
not mentally ill.
5. (if applicable) The person has
convulsive disorder.
alcoholism.
other drug dependence.
mental processes weakened by reason of advanced years.
other (specify):
6. My diagnosis is:
7. Facts serving as the basis for my determination are:
(SEE SECOND PAGE)
Do not write below this line - For court use only
CLINICAL CERTIFICATE
PCM 208 (9/16)
MCL 330.1435
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