Admission Date
formal voluntary admission application - minor
Michigan Department of Health and Human Services
Authority: Section 330.1498 of Public Act 258 of 1974 as amended. Information contained on this form is covered by Federal and State privacy and confidentiality laws. THIS LEGAL FORM IS APPROVED BY THE MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES AND CANNOT BE ALTERED OR ABRIDGED WITHOUT FORMAL APPROVAL.
To the Director of
The formal voluntary admission of	is requested.
SINCE THE PERSON TO BE ADMITTED IS A MINOR, BOTH THAT PERSON, IF ABLE TO READ, AND THE APPLICANT, MUST READ THE FOLLOWING BEFORE SIGNING THE APPLICATION.
By signing this form, the applicant agrees to these things: 1) The minor’s admission to the inpatient service, including a physical examination of the minor and any required laboratory work; 2) Administration of medication to treat medical illnesses or conditions and diagnostic procedures or treatment considered necessary by the medical staff; 3) Provision of emergency medical services at a hospital or clinic considered appropriate by the hospital medical staff if such treatment cannot be provided at this hospital; 4) Full participation of the minor in the treatment program.
LENGTH OF ADMISSION This admission is temporary, and the minor will be discharged when he or she is no longer clinically suitable for inpatient treatment. A Community Mental Health Agency will be involved in the minor's treatment and discharge planning.
OBJECTION TO HOSPITALIZATION When a minor is admitted to this hospital, he or she has a right to object to the hospitalization. The minor may say that he or she does not need to be in the hospital in order to receive the needed treatment or say that he or she does not need mental health treatment at all. This objection must be made in writing and sent to the Probate Court. A minor who is at least 14 years old may make his or her own objection. If the minor is less than 14 years old, the Probate Court must be asked to name a person to make the objection for the minor. If the patient tells the hospital staff that he or she wants to object, the staff must do the following things: 1) Explain the times that objections can be made
Objections to hospitalization can be made at the following times: Before admission After seven days but before thirty-one days after admission Within the 30-day period after the hospital reviews the person’s suitability for continued hospitalization. These reviews are held 90 days after admission and every 60 days after that.
2) Provide the proper form. 3) Help complete the form if needed. 4) Send the objection or the request to object to the Probate Court.

Formal Voluntary Admission Application for	(minor)
After the court receives the objection, it must hold a hearing within 7 days, not including Sundays or holidays. The patient must stay in the hospital until the hearing is held. If the court AGREES with the objection it will order that you be discharged from the hospital. If the court DOES NOT AGREE, the patient must stay in the hospital. The court may not make a person stay in the hospital just because the family or guardian cannot or will not take care of that person. If such a situation does exist, the hospital must file a neglect petition on behalf of the patient.
INTENT TO TERMINATE HOSPITALIZATION The APPLICANT may submit a DCH-2419-A, Notice of Intent to Terminate the Hospitalization of a Minor. The notice must be in writing and the hospital must supply the form as soon as the applicant asks for it. If such a notice is given to the hospital, the hospital may continue to keep the minor for up to 3 days not including Sundays or holidays. During that 3 days the hospital director must decide whether or not the minor is harmful to him or herself or to others; or whether he or she is not able to attend to, or allow someone else to attend to, his or her basic needs. If any of those conditions exists, the hospital will file a petition with the probate court, asking for the court to overrule the applicant's request. The minor must remain in the hospital until the court hearing is held.
ABILITY TO PAY The legal parents of the minor are responsible to pay the Department of Health and Human Services for hospital services in accordance with their ability to pay. The minor may be responsible for part of the cost of care in accordance with his or her ability to pay. The APPLICANT must give any information required by law to the hospital Reimbursement Office. Information about the financial determination and the appeal process will be given to the applicant by the Reimbursement Office. THE APPLICANT AGREES TO DISCLOSE SUCH INFORMATION, AS IS REQUIRED BY LAW, TO DETERMINE THE INDIVIDUAL'S AND OTHER LEGALLY RESPONSIBLE INDIVIDUAL'S ABILITY TO PAY FOR MENTAL HEALTH SERVICES. THE APPLICANT UNDERSTANDS THAT, IF THE MENTAL HEALTH SERVICES ARE STATE SUPPORTED, DETERMINATION OF ABILITY TO PAY WILL BE MADE BY THE DEPARTMENT OF AND HUMAN SERVICES SUBSEQUENT TO ADMISSION AND A NOTICE OF THE DETERMINATION AND APPEAL PROCEDURE WILL BE SENT TO THE INDIVIDUAL AND OTHER LEGALLY LIABLE PERSONS AS REQUIRED BY DEPARTMENT REGULATIONS.
NO ASSUMPTION OF LEGAL INCOMPETENCE Both the PERSON TO BE ADMITTED and the APPLICANT need to know that Section 330.1489 of Public Act 258 of 1974 as amended, (the Mental Health Code) states that: 1) No determination that a person requires treatment, no order of court authorizing hospitalization or assisted outpatient treatment, nor any form of admission to a hospital GIVES rise to a presumption of, constitute a finding of, or operate as an adjudication of legal incompetence. (2) No order of commitment under any previous statute of this state, in the absence of a concomitant appointment of a guardian, CONSTITUTES a finding of or OPERATES as an adjudication of legal incompetence.
CONSENT AND AUTHORIZATION The applicant consents to and authorizes the hospital to provide treatment including medication but understands that consent to electroshock, psychosurgery, experimental drugs, and surgical procedures must be obtained separately by the hospital.

Formal Voluntary Admission Application for	(minor)
PERSON TO BE ADMITTED
Name
Address	City	State
Phone	Birth Date	County Residence
APPLICATION INFORMATION
Name
Address	City	State
Phone	Birth Date	County Residence
Relationship to Person Requiring Treatment
Self Parent Legal Guardian MDHHS Worker Person in Loco Parentis (explain)
ACKNOWLEDGEMENT OF PROVISION OF A WRITTEN AND ORAL EXPLANATION OF THE RIGHTS OF RECIPIENTS OF MENTAL HEALTH SERVICES (MCL 330.1416; MCL 330.1706)
Signature of Applicant	Date	Time
Signature of Applicant	Date	Time
Signature of Applicant	Date	Time
PERSON DESIGNATED BY APPLICANT TO RECEIVE A COPY OF THIS APPLICATION
Name
Address	City	Zip Code
Date Mailed or Given	By
A determination of clinical suitably for formal voluntary admission shall be based on one of the following criteria: a) The individual has a condition that the hospital director determines can benefit from the inpatient treatment that is offered by the hospital; b) Appropriate alternatives to hospitalization have been considered by the hospital, and, with the consent of the individual, the Community Mental Health program in the individual’s county of residence; c) Adequate alternative treatment is not available or suitable at the time of admission as determined by the hospital and, with the consent of the individual, the Community Mental Health program in the individual’s county of residence.

ACTION BY THE HOSPITAL
Clinically Suitable for Admission	Not Clinically Suitable for Admission
If determined to be not clinically suitable described rational for decision
Physician Name	Date	Time
Physician Signature	Authorization Date (if different from signature date)