Fill and Sign the Emergency Detention by Form

ME -901 , 05/14 Statement of Emergency Detention by Law Enforcement Officer §51.15(4) and (5), W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF THE CONDITION OF Name of Subject Statement of Emergency Detention by Law Enforcement Officer Date of Birth Court Case No. Law Enforcement Agency No. • File this statement with the court immediately and with the detention facility upon admission . A probable cause hearing must be held within 72 hours after the subject is taken into custody . (In Milwaukee County , file this statement with detention facility only.) • Please print or type all information below. All blanks must be filled in. I am a law enforcement of fice r and have cause to believe that : • The subject is mentally ill, drug dependent, or developmentally disabled. • The subject evidences behavior which constitutes a substantial probability of physical harm to self or to others, or as otherwise set forth in §51.15(1), W isconsin Statutes. • Taking the subject into custody is the least restrictive alternative appropriate to the subject’s needs. My belief is based on specific and recent dange rous acts, attempts, threats, omissions , and/or statements made by the subject as observed by me or reliably reported to me as stated below: Dangerous Behavior When: Where: Describe Behavior: See attached page Witnesses to the dangerous behavior : (including officers who observed behavior) Name of Witness Telephone Mailing Address Relationship [Name ] of the County d epa rtment of community programs (§51.42 (3) , Wis. Stats .) board approves the need for this detention . The subject was taken into custody for the purposes of this emergency detention on [Date] at [Time] am. pm. The potential detention facility is . . Subject’s Street Address City County State Zip Code Phone Number DISTRIBUTION: 1. Court Signature of Officer Department 2. §51.15(2) Detention Facility 3. Subject with Notice of Rights Name Printed or Typed Telephone