Fill and Sign the Petition for Examination Fifth Standard under 51201a2e Wisconsin Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF THE CONDITION OF       Name of Subject Petition for Examination (Fifth Standard Under §51.20(1) (a)2.e, Wis. Stats.)       Date of Birth Case No.       Under oath, we petition the court to examine the condition of the subject, who resides in       County at       , and allege that: Address a. The subject is mentally ill and a pro per subject for treatment because:       Attach additional page if necessary. b. There exists all of the following for the subject: 1. The advantages and disadvantages of and alternatives to accepting a particular medication or treatment have been recently explained to the subject on       ; and Date 2. Due to mental illness, the subject is incapable of expressing an understanding of the advantages and disadvantages of accepting medication or treatment and the alternatives available, or the subject is substantially incapable of applying an understanding of the advantages and disadvantages and alternatives to his or her own mental illness in order to make an informed choice as to whether to accept or refuse medication or treatment; and 3. There is a substantial probability, as demonstrated by both the subject's treatment history and the subject's recent acts or omissions, that the subject needs care or treatment to prevent further disability or deterioration, and further, there exists a substantial probability that if left untreated the subject will lack the services necessary for his or her health or safety, and will suffer severe mental, emotional or physical harm that will result in loss of ability to function independently in the community or the loss of cognitive or volitional control over the subject's thoughts or actions; and 4. There is a reasonable probability that the subject will not avail himself or herself of services in the community for care or treatment necessary to prevent the subject from suffering severe mental, emotional or physical harm, and the subject is not appropriate for protective placement under §55.06, Wisconsin Statues. c. The following petitioner(s) has personal knowledge of the conduct of the subject: Name Address Telephone Relationship to Subject 1)                         2)                         3)                         ME-913 , 12/02 Petition for Examination (Fifth Standard Under §51.20(1)(a)2.e, Wis. Stats.) §51.20(1)(a)2.e, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Petition for Examination (Fifth Standard Under §51.20(1)(a)2.e, Wis. Stats.) Page 2 of 2 Case No. d. The following petitioner(s) does not have personal knowledge of the conduct of the subject but bases his/her belief on the following: Name Address Telephone Relationship to Subject 1)                         Basis for Belief:       2)                         Basis for Belief:       e. In addition to the petitioners, the following person(s) may testify in support of this petition: Name Address Telephone                                     f. The names and post office address of subject's: (If unknown or inapplicable, so state.) Spouse Post Office Address             Adult Children Post Office Address                         Parents or Guardian Post Office Address             Custodian Post Office Address             Brothers/Sisters Post Office Address                         Person(s) With Whom Subject Resides Post Office Address             Subscribed and sworn to before me on       Notary Public/Court Official, State of Wisconsin My commission expires       Signature of Petitioner Name printed or Typed                   ME-913 , 12/02 Petition for Examination (Fifth Standard Under §51.20(1)(a)2.e, Wis. Stats.) §51.20(1)(a)2.e, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2