Fill and Sign the Individual under Protective Placement or Receiving Protective Services Form

GN -4380, 05/17 Petition to Modify Protective Placement or Protective Services §§55.12(3)(4) and (5) and 55.16, 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 Petition to Modify Protective Placement or Protective Services Date of Birth Case No. UNDER OATH, I STATE: 1. I am interested as the individual under protective placement or receiving protective services. the individual’s guardian. the individual’s legal counsel or guardian ad litem. the Wisconsin Department of Health Services . the county department that placed the individual or provided the protective services un der an order of the court. an agency with which the county department contracts under §55.02(2) , W is. Stats . an interested person: 2. There has has not been a h earing held within the previous 6 months on a court -ordered protective placement for the individual or on a petition for court -ordered protective services or transfer of protective placement with respect to the individual. MODIFICATION OF ORDER FOR PROTECTIVE PLACEMENT 3. This individual is currently placed in: Name of facility Address of facility Name of Contact Person Phone Number of Contact Person 4. The protective placement is not in the least restrictive environment because protective placement :  is not the least restrictive environment and the least restrictive manner that is consistent with the needs of the individual and with the resources of the county department.  is not consistent with the factors required to be considered by the county department i n providing protective placement.  is not consistent with the required funding that the county is required to provide. in a facility with a higher level of restrictiveness would be :  in the least restrictive environment and the least restrictive manner that is consistent with the needs of the individual and with the resources of the county department.  consistent with the factors required to be considered by the county department i n providing protective placement.  consistent with the required funding that the county is required to provide. in a different facility with the same level of restrictiveness a s the current placement would be more :  consistent with the factors required to be considered by the county department in providing protective placement .  consistent with the required funding that th e county is required to provide for reasons unrelated to the level of restrictiveness. 5. The specific facts underlying the request for modification are as follows: See attached Petition to Modify Protective Placeme nt or Protective Services Page 2 of 2 Case No. GN -4380, 05/17 Petition to Modify Protective Placement or Protective Services §§55.12(3)(4) and (5) and 55.16, W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 MODIFICATION OF ORDER FOR PROTECTIVE SERVICE S 6. Protec tive services (other than involuntary administration of psychotropic medication) are not being provided in the least restrictive environment or manner because protective services:  are not in the least restrictive environment and the least restrictive manner that is consistent with the needs of the individual and with the resources of the county department.  are not consistent with the factors required to be considered by the county department in providing protective services.  are not consistent with the required funding that the county is required to provide. 7. Modification of the order or treatment plan for involuntary administration of psychotropic medi cation for the individual would be in his/her best interests. 8. The specific facts underlying the request for modification are as follows: See attached I REQUEST THE COURT : 1. Order a hearing on this petition. 2. Make appropriate findings as requested above. 3. Order modification of the protective placement for the individual that is consistent with the requirements for providing protective placement. 4. Order modification of the protective services for the individual that is consistent with the requirements for providing protective services. 5. Order modification of the order or treatment plan for involuntary administration of psychotropic medication for the individual that is consistent with the requirements for providing protecti ve services. 6. Award appropriate fees and costs. County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Petitioner Name Printed or Typed Address Date Name of Attorney Address Telephone Number Bar Number