Legal Protective Placement Petition

LEGAL PROTECTIVE PLACEMENT PETITION

Petitioner Name:   Petitioner Relationship to Proposed Person:

Proposed Protected Person Name:   Date of Birth:

Current Address:

RECITALS

WHEREAS, Petitioner believes that the Proposed Protected Person named above is incapacitated and is in need of protective placement for the person because the person lacks sufficient understanding or capacity to make or communicate responsible decisions concerning the person's health or safety; and

WHEREAS, the Proposed Protected Person has a diagnosis or condition substantially impairing functional capacity described as: ; and

WHEREAS, Petitioner contends that less restrictive alternatives have been considered and that protective placement is necessary to prevent serious harm to the Proposed Protected Person's health or safety.

NOW THEREFORE

Petitioner respectfully petitions the Court for an order authorizing protective placement of the Proposed Protected Person and for related relief as set forth below.

1. JURISDICTION AND VENUE

1.1 This Court has jurisdiction under the applicable statutes governing protective placements. Venue is proper in this Court because the Proposed Protected Person resides at the address stated above.

2. PETITIONER

2.1 Petitioner is an interested person and is authorized to bring this petition as . Petitioner may be contacted at:

3. PROPOSED PROTECTED PERSON

3.1 The Proposed Protected Person is a person alleged to be incapacitated and in need of protective placement. The person's current functional limitations and specific behaviors or deficits are described as follows:

3.2 Known next of kin, agents under advance directive, or other interested persons:

4. FACTS SUPPORTING NEED FOR PROTECTIVE PLACEMENT

4.1 The following factual allegations support the finding that protective placement is necessary to prevent imminent or likely harm to the Proposed Protected Person:

5. LESS RESTRICTIVE ALTERNATIVES

5.1 Petitioner has considered and attempted the following less restrictive alternatives, which have proven inadequate or inappropriate for the Proposed Protected Person:

6. MEDICAL AND PROFESSIONAL EVALUATIONS

6.1 Attached to this petition are written evaluations by licensed professionals that address the Proposed Protected Person's cognitive and functional status, including at minimum a physician's statement and, if available, a psychological assessment. Summaries of those evaluations:

7. PROPOSED PLACEMENT, POWERS, AND LIMITATIONS

7.1 Petitioner requests that the Court order protective placement at the following facility or class of facilities:

7.2 Petitioner requests that protective placement include only those powers necessary for the care, custody, and supervision of the person's health and safety, and specifically requests the authority to:

8. DURATION AND REVIEW

8.1 Petitioner requests that placement be ordered for an initial period of , and that the Court set periodic review at intervals not to exceed to evaluate continued need.

9. RIGHTS PRESERVED

9.1 Protective placement is an extraordinary remedy. To the extent consistent with safety and the Court's order, the Proposed Protected Person shall retain all rights not expressly limited, including the right to receive visitors, to communicate privately with counsel, and to have reasonable access to personal property, subject to facility rules and Court orders.

10. NOTICE AND HEARING

10.1 Petitioner requests that the Court set a hearing on this petition and order that notice of the hearing and a copy of this petition be given to the Proposed Protected Person, the Proposed Protected Person's attorney if any, next of kin, and other interested persons as required by statute.

10.2 Preferred method of service (check all that apply):

Mail   Personal Service   Email   Fax

11. REQUEST FOR RELIEF

WHEREFORE, Petitioner requests that the Court enter an order that:

Petitioner further requests such other and further relief as the Court deems just and proper.

MISCELLANEOUS PROVISIONS

Governing Law: This petition and any order entered on it shall be governed by the statutes and case law applicable to protective placement proceedings in the jurisdiction where the petition is filed.

Entire Agreement: This petition, attachments, and any signed court order constitute the entire understanding of the parties with respect to the matters herein alleged and requested.

Severability: If any provision of an order entered on this petition is held invalid, the remaining provisions shall continue in full force and effect.

Amendments and Waiver: Any amendment or waiver of obligations requested herein must be in writing and approved by the Court. No failure or delay by any party in exercising any right shall operate as a waiver.

CERTIFICATION AND WARNING

I certify under penalty of perjury that the foregoing statements are true and correct to the best of my knowledge, information and belief, and that this petition is made in good faith.

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