Fill and Sign the Emergency Placement Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Statement of Emergency Protective Placement       Date of Birth Case No.       1. I am: a sheriff or police officer. a fire fighter. a guardian. an authorized representative of the county department or an agency with which it contracts under §55.02(2). 2. It appears probable that the individual is so totally incapable of providing for the individual’s own care or custody as to create a substantial risk of serious physical harm to the individual or others as a result of developmental disabilities, degenerative brain disorder, serious and persistent mental illness or other like incapacities if not immediately placed in an appropriate medical or protective placement facility. The specific factual information that is the basis for the emergency protective placement, based on personal observation or a reliable report by a person identified to me, is as follows: See attached       3. A petition for protective placement is being filed with this statement. A petition for guardianship is also being filed unless: A. The individual is currently under guardianship or B. The individual is a minor who is alleged to be developmentally disabled. 4. The individual was detained at       , Name of Facility on       , at       am. pm. Date Time Subject’s Street Address       City       County       State       Zip code       Signature of Person Making Placement Name of Department and Address       Name Printed or Typed       Telephone Number       GN-4000, 10/06 Statement of Emergency Protective Placement §55.135, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material