Fill and Sign the Report Ad Litem Sample Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Name of Ward Amended Report and Recommendation of Guardian ad Litem (Annual Review)       Date of Birth Case No.       I am the court-appointed guardian ad litem for the above-named individual. I certify to the court that I have complied with the requirements of a guardian ad litem under §55.18 (2) (a) to (e), Wisconsin Statutes (except as noted in the “Additional Comments” section at the end of this report) and this report is being filed within 30 days of my appointment. 1. I have reviewed the county department’s annual report of the review of the status of the individual, the Annual Report on the Condition of the Ward, and any other relevant reports on the individual’s condition and placement. 2. I have personally met with the individual and contacted the individual’s guardian. 3. I have orally explained to the individual and to the individual’s guardian, and provided to the individual and the individual’s guardian in writing, all of the following: A. The procedure for review of protective placement. B. The right of the individual to appointment of legal counsel, and if the individual appears to be indigent, that the court shall refer the individual 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 the individual. E. That a change in or termination of protective placement may be ordered by the court. F. The right to a hearing and an explanation that the individual or the individual’s guardian may request a full due process hearing. 4. I have reviewed the individual’s condition, placement, and rights with the individual’s guardian, and I have ascertained whether the individual wishes to exercise any of the individual’s rights. Based on these reviews, I make the following report: A. Individual’s current living arrangement is: a nursing facility. an intermediate facility. a center for developmentally disabled. a CBRF. an adult family home. Other:       Name of Facility:       Is the home or facility licensed for 16 beds or greater? No Yes B. The individual appears to continue to meet all the standards for protective placement. Yes No, please explain:       C. The current protective placement is the least restrictive environment that is consistent with the individual's needs. Yes No, please explain:       D. The individual is developmentally disabled and placement is in a nursing facility or intermediate facility, and the placement is the most integrated setting appropriate to the individual’s needs. Not Applicable GN-4110,10/06 Report and Recommendation of Guardian ad Litem (Annual Review of Protective Placement) §55.18(2), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 GN-4110 Report and Recommendation of Guardian ad Litem (Annual Review) Page 2 of 2 Case No. Yes No, please explain:       E. An independent evaluation is requested by the individual, the individual’s guardian ad litem or guardian. No Yes, please explain:       F. The individual or the individual’s guardian requests modification or termination of the protective placement. No Yes, please explain:       G. The individual or the individual’s guardian requests or the guardian ad litem recommends that legal counsel be appointed for the individual. No Yes, please explain:       H. The individual or the individual’s guardian or the guardian ad litem requests a full due process hearing for the individual. No Yes, please explain:       5. I recommend continued protective placement in the facility in which the individual resides at this time. Yes No, please explain:       6 . Additional comments:       Signature of Guardian ad Litem       Name Printed or Typed       Date GN-4110 10/06 Report and Recommendation of Guardian ad Litem (Annual Review of Protective Placement) §55.18(2), Wisconsin Statutes. This form shall not be modified. It may be supplemented with additional material. Page 2 of 2