Fill and Sign the 201a2 Form

ME-913, 05/13 Petition for Examination (Fifth Standard Under §51.2 0(1)(a)2.e, Wis. Stats.) §51.20(1)(a)2.e, W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF THE CONDITION OF Name of Subject Petition for Examination (Fifth Standard Under §51.20(1)(a)2.e, Wis. Stats.) Date of Birth Case No. This document was drafted by County Corporation Counsel [Name] as required by law. Under oath, we petition the court to examine the condition of the subject, who resides in [County] at [Address] , and allege that A. the subject is mentally ill and a proper subject for treatment because: Attach additional page if necessary. B. all of the following exists for the subject: 1. The advantages and disadvantages of and alternatives to accepting a particular medication or tr eatment have been recently explained to the subject on [Date] ; and 2. Due to mental illness, the subject is incapable of expressing an understanding of the advantages and disadvantages of accepting medication or treatment and the alternatives available, or the subject is substantially incapable of applying an understanding of the advantages and disadvantages and alternatives to his or her own mental illness in order to make an informed choice as to whether to accept or refuse medication or treatment; and 3. There is a substantial probability, as demonstrated by both the subject's treatment history and th e subject's recent acts or omissions, that the subject needs care or treatment to prevent further disability or deteri oration, and further, there exists a substantial probability that if left untreated the subject will lack the services necessary for his or her health or safety, and will suffer severe mental, emotional or physic al harm that will result in loss of ability to function independently in the community or the loss of cogni tive or volitional control over the subject's thoughts or actions; and 4. There is a reasonable probability that the subject will not avail himself or hers elf of services in the community for care or treatment necessary to prevent the subject from suffering severe mental, emotional or physical harm, and the subject is not appropriate for protective placement under §55.06, Wisconsin Statu es. C. the following petitioner(s) has personal knowledge of the conduct of the subject: Name Address Telephone Relationship to Subject 1) 2) 3) Petition for Examination (Fifth Standard under §51.20(1)(a)2.e, Wis. Stats.) Page 2 of 2 Case No. ME-913, 05/13 Petition for Examination (Fifth Standard under §51.20 (1)(a)2.e, Wis. Stats.) §51.20(1)(a)2.e, W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 2 of 2 D. the following petitioner(s) does not have personal knowledge of the conduct of the subject bu t bases his/her belief on the following: Name Address Telephone Relationship to Subject 1) Basis for Belief: 2) Basis for Belief: E. in addition to the petitioners, the following person(s) may testify in support of this petition: Name Address Telephone F. the names and post office address of subject's: (If unknown or inapplicable, so state.) Spouse Post Office Address Adult Children Post Office Address Parents or Guardian Post Office Address Custodian Post Office Address Brothers/Sisters Post Office Address Person(s) With Whom Subject Resides Post Office Address State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: SIGNATURE OF PETITIONER NAME PRINTED OR TYPED