Fill and Sign the Work of the Juvenile Court Unit is Governed by the Form

JD-1710, 02/18 Temporary Physical Custody Request (Chapter 938) Chapter 938,W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Temporary Physical Custody Request (Chapter 938) Referring Agency Case Number Intake Case Number Court Case Number Requesting Agency Complete Juvenile's Name (Last, First, Middle) African American Asian or Pacific Island er Am erica n Ind ian or Alaskan Native Hispanic Caucasian Unknown Other Date of Birth Male Female Juvenile's Address If Americ an Indian or Alaskan Native, list tribe: Telephone Number Why was juvenile taken into custo dy? ( § 938.19 , Wis. Stats. ) Warrant/capias Order by judge Crimina l act Runaway Juvenile suffering from illness, injury or other danger Violation of terms of court -ordered supervision Violation of conditions of temporary custody order Violation of civil law or ordinance Unexcused absence from school County of Residence Parent 1 's Name and Address Legal Status: Birth Adjudicated/Adopt ive Presumed Alleged Unknown Date of Birth Home Telephone Number Wor k Telephone Number Parent 2 's Name and Address Legal Status: Birth Adjudicated/Adopt ive Presumed Alleged Unknown Date of Birth Home Telephone Numb er Work Telephone Number Legal Guardian's Name and Address Date of Birth Home Telephone Number Work Telephone Number Date and Time Taken Into Custody Taken Into Custody By Agency The parents notified by referring party? Yes (Date and Time) No Additional information on notice: Why was juvenile not released? Supporting facts of reason why juvenile was taken into physical custody ( §938.20(3) , Wis. Stats. ): See attachment Copy provided to juvenile , if age 1 0 or over: Yes No Intake Worker Complete Was juvenile notified of r ight to counsel and right against self -incrimination? (§938.20( 7)(a), Wis. Stats. ) Yes No Were notice of custody decision and hearing rights provided ? (§938.20(8) , W is. Stats. ) Juvenile: Yes, Date and Time: No Parent 1: Yes, Date and Time: No Parent 2 : Yes, Date and Time: No If no, what ongoing efforts have been made to notify? Jurisdictional Basis : 1. No Jurisdiction. 2. Delinquency: § 3. JIPS (§938.13): uncontrollable. habitually truant from school. school dropout. habitually truant from home. delinquent act before age 10. not res ponsible or not competent. Custody Criteria: (§938.205 , Wis. Stats. ) 1. Juvenile will commit injury to person or property of others. 2. Juvenile will: cause injury to self. be subject to injury by others. run aw ay or be taken away so as to be unavailable for further court proceedings. 3. Parent, guardian, legal custodi an or other responsible adult is: neglecting refusing unable unavailable to provid e adequate supervision and care . Temporary Physical Custody Request (Ch. 938) Page 2 of 2 Case No. JD-1710 , 02/18 Temporary Physical Custody Request (Chapter 938) Chapter 938,W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 Intake Worker Comp lete Placement Decision: 1. Juvenile released. 2. Nonsecure custody: (§938.207 , Wis. Stats. ) a. At the home of a parent. relative. guardian. person not a relative. b. At licensed foster home, treatment foster home, or group home. c. At non -secure facility operated by a licensed child welfare agency. d. At licensed private or public shelter care facility (including holdover room). e. At hospi tal or phy sician's office if the juvenile is believed to be suffering from a serious physical condition which requires either prompt diagnosis or prompt treatment . f. At licen sed treatment facility approved by the county as the juvenile is belie ved to have a mental illness or developmental disability or to be drug dependent and exhibits conduct that constitutes a substantial probability of physical harm to the juvenile or to ot hers, or a very substantial probability of physical impairment or injury to the juvenile exists due to the impaired judgment of the juvenile . g. At approved public treatment facility for emergency treatment as the juvenile is believed to be an intoxicated person who has threatened, attempted or inflicted physical harm on himself or herself or on another and is likely to inflict such physical harm unless committed, or is incapacitated by alcohol . h. At the county children’s home. 3. Secure custody because: (§938.208 , Wis. Stats. ) a. Juvenile has committed a delinquent act and there is a substantial risk of: physical harm to another. runaway. b. Juvenile has: committed a felony delinquent act listed under §938.208 (1)(a) , Wis. Stats. committed a felony delinquent act whil e in possession of a firearm. possessed a short -barreled rifle, short -barreled shotgun, or handgun. c. Juvenile is a: fugitiv e from another state runaway from a juvenile correctional facility and there has been no reasonable opportunity to return the juvenile. d. A protective order has been issued and the juvenile consents in writing to the placement. e. Juvenile has run away or committed a delinquent act while in nonsecure custody. f. Juvenile is alleged/adjudicated delinquent and is a runaway from another county and would run away from nonsecure placement. g. Juvenile is subject to the jurisdiction of the adult criminal court and is under 15 years of age. 4. This is a secure custody placement in a jail because: (§938.209 , Wis. Stats. ) a. No other approved juvenile detention facility is available. b. Juvenile is a substantial risk of physical harm to others in a juvenile detention facility. Placement in the home is contrary to the welfare of the juvenile, due to: Efforts made to prevent removal and return the child safely to the home include: Name of Placement Not disclosed to parent due to imminent danger Address Telephone Number Special precautions/information concerning juvenile/family Signature of Intake Worker Date and Time Custody Authorized Date and Time of Custody Hearing Date and Time of Release