Fill and Sign the Admission Section Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF THE CONDITION OF       Name of Subject Statement of Emergency Detention view Of Admission ( § 51.13)       Date of Birth Case No.       • File this statement with the court within three (3) days after admission or an application for admission has been executed, whichever is sooner. The Court must either approve the admission within 5 after filing the Petition or hold a hearing within seven (7) days after admission or an application for admission has been executed. • A copy of the application for admission and any relevant professional evaluations must be attached. • Please print or type all information below. All blanks must be filled in. I am a treatment director/treatment director’s designee of       and state: Mental Health Facility The minor, 14 years of age or older, refuses consent for admission. The minor, any age, exhibits, verbally and/or behaviorally, refusal of consent for admission. The minor, minor’s counsel, parent, or guardian requests a hearing. The minor’s inpatient psychiatric hospitalization exceeds 12 days. The minor has been hospitalized, psychiatrically, within past 120 days. Date of admission:       Anticipated date of discharge:       Patient’s Street Address       City       County       State       Patient’s Legal Guardian’s name(s) and Street Address       City       County       State       I am a treatment director/treatment director’s designee and have reason to believe: 1. The minor is in need of psychiatric services, or services for developmental disability, alcoholism, or drug abuse based on the following facts:       2. Inpatient treatment in this inpatient facility is appropriate based on the following facts :       ME 921, 04/07 Statement of Petition for Review of Admission ( § 51.13) §51.13(4)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Statement of Petition of Petition Page 2 of 2 Case No. For Review of Admission ( § 51.13) 3. Inpatient care in this facility is the least restrictive setting consistent with the treatment needs of the minor based on the following considerations:       4. The minor has expressed his or her wishes regarding inpatient treatment at this facility through the following statement(s) and/or behaviors:       Signature of Treatment Director or Designee       Date Distribution: 1. Original - Court 2. Minor 3. Parent(s)/Legal Guardian(s) 4. Division of Disability and Elder Services ME-921, 04/07 Statement of Petition for Review of Admission ( § 51.13) §51.13(4)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2