Fill and Sign the Name Statement of Emergency Protective Placement Form

GN -4030, 04/08 Order on Temporary Protective Placement or Protective Services §§55.10(4) and 55.135, W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Amended Order on Temporary Protective Placement or Protective Services Date of Birth Case No. A Statement of Emergency Protective Placement has been filed with a petition for guardianship and protective placement protective placement of the individual and a preliminary hearing has been held to determine whether probable cause exists for protective placement . The court has considered testimony and other evidence presented and gua rdian ad litem’s recommendation. THE COURT FINDS: 1. Probable cause has not been established. 2. Probable cause that the individual needs protective placement and m eets the standards for protective placement because:  The individual has a primary need for residential care and custody.  Except in the case of a minor that is age 14 or older, who is alleged to have a developmental disability , the individual has either been adjudicated to be incompetent by a circuit court or a petition for guardianship has been submitted on the minor’s behalf;  As a result of a developmental disability, degenerative brain disorder, serious and persistent mental illness, or other like inca pacities, the individual is so totally incapable of providing for his or her own care or custody as to create a substantial risk of serious harm to himself or herself or others. Serious harm may be evidenced by overt acts or acts of omission.  The individua l has a disability that is permanent or likely to be permanent. 3. Probable cause to believe that the individual meets the standards for protective services because:  the individual has been determined to be incompetent or is a minor alleged to have a developmental disability and a petition for guardianship has been submitted, and  as a result of a developmental disabilit y, degenerative brain disorder, serious and persis tent mental illness, or other like incapacities, the individual will incur a substantial risk of physical harm or deterioration or will present a substantial risk of physical harm to others if protective services are not provided. 4. Protective placement is not appropriate and t he court elects to treat the Petition for Protective Placement as a P etition for Commitment under §51.20 , W is. Stats., or §51.45(13) , W is. Stats . 5. Other: THE COURT ORDERS: 1. These proceedings are dismissed and the individual is released. 2. Temporary protective placement of the individual for up to 30 days pending the hearing for a permanent protective placement. Order on Temporary Protective Placement or Protective Services Page 2 of 2 Case No. ______________ GN -4030, 04/08 Order on Temporary Protective Placement or Protective Services §§55.10(4) and 55.135, W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 3. The county department or agency with which it contracts under §55.02(2), Wis. Stat s., or its designee to provide protective services to the individual as may be required. 4. This Petition for Protective Placement to be treat ed as a P etition for Commitment under §51.20 , W is. Stats., or §51.45(13) , W is. Stats . 5. Other: Name of Attorney BY THE COURT: Address Circuit Court Judge/Court Commissioner Print or Type Name if not eSigned Date Telephone Number Bar Number