Fill and Sign the Statement of Emergency Detention by Treatment Director Wisconsin Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF THE CONDITION OF       Name of Subject Statement of Emergency Detention by Treatment Director       Date of Birth Case No.       • File this statement with the detention facility and court immediately. A probable cause hearing must be held within 72 hours of detention. • Please print or type all information below. All blanks must be filled in. I am a treatment director/treatment director’s designee of       and state: Mental Health Facility • The subject is mentally ill, drug dependent, or developmentally disabled. • The subject evidences behavior which constitutes a substantial probability of physical harm to self or to others, as set forth in §51.15, Wisconsin Statutes. My belief is based on specific and recent dangerous acts, attempts, threats or omissions by the subject as observed by me or reliably reported to me as stated below: Dangerous Behavior: When:       Where:       Describe Behavior:       See attached page. Witnesses to the dangerous behavior: Name of Witness Telephone Address Relationship                                                                                                 The subject was detained on       , at       am. pm. (Detention occurs when subject requests discharge.) Date Time ME-902 , 12/02 Statement of Emergency Detention by Treatment Director §51.15, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Statement of Emergency Detention by Treatment Director Page 2 of 2 Case No. Subject’s Street Address       City       County       State       Distribution: 1. Court – Original 2. Subject with Notice of Rights Signature of Director or Designee Name Printed or Typed       Telephone       ME-902 , 12/02 Statement of Emergency Detention by Treatment Director §51.15, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2