Pcm 208 - Clinical Certificate - State Of Michigan Probate Court County Page 2
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1
2Clinical Certificate (9/16)
File No.
8. Explain in the space below the facts which lead you to believe that future conduct may result in
(check applicable box)
a. likelihood of injury to self. Facts:
Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near
future to intentionally or unintentionally seriously physically injure self.
b. likelihood of injury to others. Facts:
Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near
future to intentionally or unintentionally seriously physically injure others.
c. inability to attend to basic physical needs. Facts:
Therefore, I believe that the examined person, as a result of mental illness, is unable to attend to those basic physical
needs (such as food, clothing or shelter) that must be attended to in order to avoid serious harm in the near future.
d. inability to understand need for treatment. Facts:
Therefore, I believe that the examined person, as a result of mental illness, is so impaired by that mental illness that s/he
is unable to understand the need for treatment, and his/her impaired judgment presents a substantial risk of significant
physical or mental harm to himself/herself or presents a substantial risk of physical harm to others in the near future.
9. I conclude the individual
is
is not
a person requiring treatment.
10. (optional) I recommend
hospitalization
alternative treatment
as follows:
.
I certify that I am a person authorized by law to certify as to the individual's mental condition. I am not related by blood or
marriage either to the person about whom this certificate is concerned or to any person who has filed, or whom I know to be
planning to file, a petition in this proceeding. I declare under the penalties of perjury that this certificate has been examined by
me and that its contents are true to the best of my information, knowledge, and belief.
Date
Time of signing
Signature
Print or type name and business telephone no.
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