Fill and Sign the Order on Petition Objecting to Transfer of Protective Placement Wisconsin Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Order on Petition Objecting to Transfer of Protective Placement       Date of Birth Case No.       This matter is before the court on a Petition Objecting to Transfer of Protective Placement and a hearing has been held. The court has considered testimony, reports and other evidence presented, the guardian ad litem's report and recommendation and other information as follows:       THE COURT FINDS: 1. The individual who is the subject of this proceeding: A. continues to have a primary need for residential care and custody. B. continues to be incompetent, as a result of: developmental disabilities degenerative brain disorder serious and persistent mental illness other like incapacities or is a minor alleged to be developmentally disabled and a petition for guardianship has been submitted on the minor’s behalf. C. continues to be 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, with serious harm being evidenced by overt acts or acts of omission; and D. continues to have a disability which is permanent or likely to be permanent. 2. The individual no longer meets the standards for protective placement . 3. The proposed transfer: A. meets the standards for transfer because: the transfer is to a locked unit and court has made a specific finding as to the need. the individual has developmental disabilities and the transfer is to an intermediate facility or nursing facility with the development of a community plan or a community plan being furnished to the county department or agency and to the individual’s guardian. the transfer is to the least restrictive environment and in the least restrictive manner, consistent with the needs of the individual and the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds. the transfer is to an intermediate facility or nursing facility that is in the most integrated setting that enables an individual to interact with persons without developmental disabilities to the fullest extend possible. the transfer is in the best interest of the individual. Other:       See attached. B. does not meet the standards for transfer because: the transfer is to a unit for the acutely mentally ill. the transfer is to a locked unit without a specific finding from the court as to the need. the individual has developmental disabilities and the transfer is to an intermediate facility or nursing facility without development of a community plan or a community plan being furnished to the county department or agency and to the individual’s guardian. the transfer is not to the least restrictive environment and in the least restrictive manner, consistent with the needs of the individual and the resources of the county department, including the limits of GN-4370, 10/06 Order on Petition Objecting to Transfer of Protective Placement §§55.08, 55.15, and 55.17, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 GN-4370 Order on Petition Objecting to Transfer of Protective Placement Page 2 of 2 Case No. available state and federal funds, and county funds required to be appropriated to match state funds. the transfer is to an intermediate facility or nursing facility that is not in the most integrated setting that enables an individual to interact with persons without developmental disabilities to the fullest extend possible. the transfer is not in the best interest of the individual. other:       See attached. 4. The individual meets the standards for protective services because: A. the individual has been determined to be incompetent by circuit court or is a minor who is alleged to be developmentally disabled and on whose behalf a petition for a guardianship has been submitted. B. as a result of developmental disabilities, degenerative brain disorder, serious and persistent 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. THE COURT ORDERS: 1. The objection is denied and the transfer is approved. 2. The objection is granted and the transfer is prohibited. 3. The protective placement is terminated. a. The individual shall be transferred or discharged from his/her current residential facility within 60 days of this order. The county department shall assist the residential facility with discharge planning for the individual including planning for proper residential living arrangements and the necessary support services for the individual. b. The individual may remain in the current facility which is licensed for fewer than 16 beds. 4. The county department or agency with which it contracts under §55.02(2), Wisconsin Statutes, or its designee shall provide protective services to the individual in the least restrictive environment and in the least restrictive manner consistent with the needs of the individual and the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds. 5. Other:       BY THE COURT: Signature of Circuit Court Judge/Commissioner       Name Printed or Typed       Date Distribution: 1. Original - Court 2. Individual 3. Individual’s Guardian 4. Individual’s Legal Counsel, if any 5. Guardian ad Litem 6. Individual’s agent under an activated power of attorney for healthcare, if any 7. Facility in which the individual resided when petition for annual review was filed 8. County Department of individual’s county of residence under §55.18(1)(a) 9. County Department of individual’s placement under §55.18(1m) GN-4370, 10/06 Order on Petition Objecting toTransfer of Protective Placement §§55.08, 55.15, and 55.17, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2