Code: APP
STATE OF MICHIGAN
PROBATE COURT
WAYNE COUNTY
AFFIDAVIT OF
PHYSICIAN OR PSYCHOLOGIST
FILE NO.
In the matter of , an individual with a developmental disability
1. I am a licensed physician psychologist in the State of Michigan.
2. I examined the above named respondent on .
Date
3. It is my professional opinion that attendance at any and all proceedings in this matter would subject the respondent to serious
risk of physical or emotional harm for the reason that:
4. I request that the respondent's presence be excused.
Name of Physician/Psychologist Telephone Number
Date
Physician/Psychologist Signature
Subscribed and sworn to before me on , County, Michigan.
Date
My commission expires:
Signature:
Date
Deputy clerk/Register/Notary public
Do not write below this line - For court use only
WCPC 35 (8/10) AFFIDAVIT OF PHYSICIAN OR PSYCHOLOGIST
MCL 330.1617(4)
