Fill and Sign the Gn 4110 Report and Recommendation of Guardian Ad Litem Annual Form

STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Amended IN THE MATTER OF Name of Ward Date of Birth Psychotropic Medication Report and Recommendation of Guardian ad Litem (Annual Review) Case No. I am the court-appointed guardian ad litem for the above-named ward. I certify to the Court that I have complied with the requirements of a guardian ad litem under §55.19 (a) to (e), Wisconsin Statutes (except as noted in the “Additional Comments” section at the end of this report) and this Report is filed within 30 days of my appointment. 1. I have reviewed the county department’s annual report of the review of the status of this ward and any other relevant reports on the ward’s condition and placement. 2. I have personally met with the ward and contacted the ward’s guardian. 3. I have orally explained to the ward and to the ward’s guardian, and provided to the ward and the ward’s guardian in writing, all of the following: A. The procedure for review of the order for involuntary administration of psychotropic medication. B. The right of the ward to appointment of legal counsel, and if the ward appears to be indigent, the Court shall refer the ward to the state public defender for a determination of indigency to qualify for legal counsel provided by the state public defender. C. The right to an independent evaluation. D. The contents of the county department’s annual report of the review of the status of this ward. E. A termination or modification of the order or modification of the treatment plan for involuntary administration of psychotropic medication may be ordered by the Court. F. The right to a hearing and an explanation that the ward or the ward’s guardian may request a full due process hearing. 4. I have reviewed the ward’s condition and rights with the ward’s guardian, and I have ascertained whether the ward wishes to exercise any of the ward’s rights. Based on these reviews, I make the following report: A. The ward appears to continue to meet all the standards for an order for involuntary administration of psychotropic medications. No Yes, please explain: B. The ward, the ward’s guardian ad litem or guardian requests an independent evaluation. No Yes, please explain: C. The ward or the ward’s guardian requests termination of the order for involuntary administration of psychotropic medication. No Yes, please explain: D. The ward or the ward’s guardian requests modification of the order for involuntary administration of psychotropic medication. No Yes, please explain: E. The ward or the ward’s guardian requests modification of the treatment plan for involuntary administration of psychotropic medication. No Yes, please explain: F. The ward or the ward’s guardian requests or the guardian ad litem recommends that legal counsel be appointed for the ward. No Yes, please explain: G. The ward or the ward’s guardian or the guardian ad litem requests a full due process hearing for the ward. No Yes, please explain: H. The ward is not required to attend a Summary Hearing. Regarding the ward's attendance at a full due process hearing for this review: it is my opinion that the ward can attend the hearing in Court. GN-4260, 05/19 Psychotropic Medication Report and Recommendation of Guardian ad Litem (Annual Review) This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 §55.19, Wisconsin Statutes I waive the ward’s attendance after considering the ability of the ward to understand and meaningfully participate, the effect of the ward’s attendance on his or her physical or psychological health in relation to the importance of the proceedings and the ward’s expressed desires. I certify the ward is unable to attend for these specific reasons: the ward is unable to attend the hearing in Court because of residency in a nursing home or other facility, physical inaccessibility, or a lack of transportation. The ward, advocate counsel, other interested person, or I request that the Court hold the hearing in a place where the ward can attend. Specify location requested: 5. I recommend continuation of the order for involuntary administration of psychotropic medication. Yes No, please explain: 6. Additional comments: Guardian ad Litem Name Printed or Typed Date GN-4260, 05/19 Psychotropic Medication Report and Recommendation of Guardian ad Litem (Annual Review) This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 §55.19, Wisconsin Statutes