Approved, SCAO |
JISCODE:ROP/ROM |
STATEOFMICHIGAN PROBATECOURT COUNTYOF
REPORTOFPHYSICIAN
ORMENTALHEALTHPROFESSIONAL
In the matter of
1. I am a licensed
, alleged incapacitated individual
mental health professional. My speciality is
if any
2.I last examined the individual on
3.Basedonthatexaminationandher/hismedicalrecord,theindividualsuffersfromthefollowingphysicalorpsychologicalinfirmities:
4. These infirmities interfere in the following ways with the individual's ability to receive or evaluate information in making decisions:
5.The following is a list of all medications the individual is receiving, the dosage of each medication, and a description of the effects ofeachmedicationupontheindividual'sbehavior:
6. |
I believe the individual, due to these described conditions, is not presently able to make informed decisions in the following areas: |
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check all that apply |
determiningwheretolive. |
handlingpersonalfinancialaffairs. |
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consentingtosupportiveservices. |
authorizing or refusing medical treatment. |
7. |
The prognosis for improvement in the individual's conditions is |
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My recommendation for the most appropriate rehabilitation plan is attached.
8. Further comments are attached on a separate sheet.
Date |
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Signature |
Address |
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Name (type or print) |
City, state, zip |
Telephone no. |
USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.
Do not write below this line - For court use only
PC 630 (9/11) REPORT OF PHYSICIAN OR MENTAL HEALTH PROFESSIONAL |
MCL 700.5304, MCR 5.405 |