Fill and Sign the Annual Review of Order Authorizing Form

STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Amended IN THE MATTER OF Order Appointing Guardian Ad Litem (Annual Review of Order Authorizing Involuntary Administration Psychotropic Medications) Name Date of Birth Case No. 1. The above-named ward is the subject of an order authorizing involuntary administration of psychotropic medications. 2. The ward resides at Address: Name of facility and contact person and phone number (if any) Facility Name: Contact Person Name: Contact Person Phone Number: 3. The name, address and telephone number of this ward’s guardian(s) is: Name Mailing Address [Street, City, State, Zip] Telephone Number 4. The Order Authorizing Involuntary Administration of Psychotropic Medications was last reviewed by the Court on [Date of last order] . 5. The county department filed the annual report for review of protective placement/protective services and the Petition for Order Authorizing Involuntary Administration of Psychotropic Medications (Annual Review). THE COURT ORDERS: 1. The appointment of the following attorney to act as guardian ad litem of the above-named ward: Attorney Name Street Address City, State, Zip Phone Number 2. The guardian ad litem shall: A. review the county department’s annual report of the review of the status of this ward, the Annual Report on the Condition of the Ward, and any other relevant reports on the ward’s condition and continued need for the Order Authorizing Involuntary Administration of Psychotropic Medications. B. meet with the ward and contact the ward’s guardian and advise them orally and in writing of: GN-4240, 05/19 Order Appointing GAL (Annual Review of Order for Involuntary Administration of Psychotropic Medications) This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 §55.19(2), Wisconsin Statutes  the procedure for review of Order Authorizing Involuntary Administration of Psychotropic Medications,  the ward’s rights in this proceeding,  the contents of the report of the annual review of this ward by the county department, and  a change in or termination of the order may be ordered by the Court. C. review the ward’s condition and rights with the ward’s guardian. D. ascertain whether the ward wishes to exercise any of his or her rights. E. file the Psychotropic Medication Report and Recommendation of the Guardian ad Litem (Annual Review) within 30 days of this Order, by [Date] . 3. Other: DISTRIBUTION: 1. Court 2. Ward 3. Ward’s Guardian 4. Corporation Counsel 5. Ward’s Legal Counsel 6. Guardian ad litem 7. Ward’s agent under Power of Attorney for Health Care 8. Facility in which the ward resides 9. County Department of Human Services/Social Worker GN-4240, 05/19 Order Appointing GAL (Annual Review of Order for Involuntary Administration of Psychotropic Medications) This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 §55.19(2), Wisconsin Statutes