Fillable FILE NO. REPORT TO ACCOMPANY PETITION TO STATE (Michigan)

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FILE NO. REPORT TO ACCOMPANY PETITION TO STATE (Michigan)

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In the matter of , an individual with an alleged developmental disability
1. I, , report to the court that:
2. The individual's developmental disability may be described as follows:
Nature:
Type:
3. The appended evaluations are current, take into account the individual's abilities, and were performed and signed by the
following individuals:
Mental
Physical
Social
Educational
Adaptive Behavior
Social Skills
4. Appended to the report is a listing of all psychotropic medication, plus all other medication that the individual is receiving on
a continuous basis, the dosage of the medication, and a description of the impact upon his or her mental, physical and
educational condition, adaptive behavior, and social skills.
should be modified
5. Guardianship is needed for the following reason(s):
is not needed.
PLEASE SEE OTHER SIDE
Do not write below this line - For court use only
OSM CODE: RPD
FILE NO.
Approved, SCAO
Name (type or print)
MCL 330.1612; MSA 14.800(612)
Evaluation Name Title Date Performed
REPORT TO ACCOMPANY PETITION TO
APPOINT, MODIFY OR DISCHARGE
GUARDIAN OF INDIVIDUAL WITH
DEVELOPMENTAL DISABILITY
STATE OF MICHIGAN
PROBATE COURT
COUNTY
CIRCUIT COURT - FAMILY DIVISION
PC 659 (3/00) REPORT TO ACCOMPANY PETITION TO APPOINT, MODIFY OR DISCHARGE GUARDIAN OF INDIVIDUAL
WITH DEVELOPMENTAL DISABILITY
6. The type and scope of guardianship services needed are as follows:
7. The recommendations and reasons for the most appropriate rehabilitation plan are as follows:
8. The recommendations and reasons for the most appropriate living arrangements are as follows:
The guardian should be authorized to make application to place the individual in
.
City, state, zip
Address
Name of center or agency
Telephone no.
Date
Signature of person preparing report
Name or type of facility
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FILE NO. REPORT TO ACCOMPANY PETITION TO STATE (Michigan)

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Completed 30 August 2020

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