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JD-1732 , 11/15 Order for Examination or Assessment §§48.295 and 938.295, W isconsin Statutes This form shall not be modified. It may be supp lemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY For Official Use IN THE INTEREST OF Name Order for Examination or Assessment Date of Birt h Case No. THE COURT FINDS: 1. Reasonable cause to order an examination or assessment. 2. There is probable cause to believe the juvenile has committed the alleged offense and there is reason to doubt the juvenile’s competency to proceed. 3. The juvenile entered a plea of not responsible by reason of mental disease or defect. IT IS ORDERED : 1. The following examination/assessment be conducted physical examinatio n psychological examination developmental examination mental examination alcohol or other drug assessment other: of the child/juvenile . parent(s): guardian: legal custodian: 2. This examination/assessment shall be outpatient inpatient (chapter 938 only) and shall be conducted by a physician: a psychiatrist: a licensed psychologist: another expert (with a master’s degree in social work or another rela ted field of child development) an approved treatment facility for alcohol and other drug abuse: 3. This examination/assessment should evaluate the following: Physical condition . Mental competency to proceed . Psychological status . Alcohol or other drug abuse dependency . Whether the juvenile at the time of commission of the alleged delinquent act was not responsible by reason of mental disease or defect . Mental condition . Developmental condition . Abili ty of the parents to care for the child/juvenile . Appropriateness of medication, including psychotropic medications . other: Order for Examination or Assessment Page 2 of 2 Case No. JD-1732 , 11/15 Order for Examination or Assessment §§48.295 and 938.295, W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 4. The costs of th is examination shall be paid by the parents, guardian or legal custodian: insurance company of child/juvenile/parents/guardian/legal custodian: the county. 5. The examiners shall file the following written report with the court: Assessment : Within 14 days from the date of this order. This report shall include a recommendation whether treatment, intervention and/or educ ation is needed, and if so, shall recommend a service plan and appropriate treatment, intervention and/or education. Examination : No later than (Date) . This report must contain a description of the nature of the examination; the persons interviewed, the records reviewed, the tests administered, and the facts and reasoning upon which the opinion is based, as well as: If the exam ination is ordered because of a reason to doubt the j uvenile’s competency to proceed  an opinion regarding the juvenile’s present mental capacity to understand the proceedings and assist in his or her defense, and  if the examiner reports that the juvenile l acks competency to proceed, an opinion regarding the likelihood that the juvenile, if provided treatment, may be restored to competency within the lesser of the following time periods:  12 months.  the maximum sentence that may be imposed on an adult for th e most serious delinquent act with which the juvenile is charged: If the examination is ordered because of a plea of not responsible by reason of mental diseas e or defect, an opinion whether  the juvenile suffered from mental disease or defect at the time of commission of the alleged act, AND  if so, whether this caused the juvenile to lack substantial capacity to  appreciate the wrongfulness of his or her conduct; or,  conform his or her conduct to the requirements of la w. Other: NOTICE: If a competency or NGI evaluation is ordered, a reasonable contribution toward the cost of the evaluation(s) may be recovered from the juvenile’s parent(s) or guardian(s), based on their ability to pay. This report is to be sent to the court at: DISTRIBUTION: 1. Original - Court 2. Child/Juvenile/Attorney /GAL 3. Parents /Guardian/Legal Custodian/Attorney 4. Provider conducting examination/assessment 5. Court appointed spe cial advocate, if any 6. District attorney/Corp. C ounsel 7. Petitioning Attorney 8. Agency 9. Other: BY THE COURT: Circuit Court Judge Circuit Court Commissioner Nam e Printed or Typed Date