Fill and Sign the Wi Placement Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Notice of Transfer of Protective Placement       Date of Birth Case No.       1. The placement of the individual under protective placement is being transferred by: guardian. county department or agency with which it contracts. the Wisconsin Department of Health and Family Services. protective placement facility. 2. This transfer is being made: between protective placement units. between protective placement facilities. from a protective placement unit to a medical facility. This is not a transfer to any facility for which commitment procedures are required under Chapter 51, Wisconsin Statutes. 3. NON-EMERGENCY TRANSFER. This Notice of Transfer is being provided for a non-emergency transfer 10 days prior to the transfer to the court and to each of the persons and entities specified above who did not initiate the transfer. The guardian will provide written consent prior to the transfer. The county department will provide written consent prior to the transfer if this transfer is to a facility that is more costly to the county.  The individual under a protective placement, the individual’s attorney, if any, or other interested person has the right to petition the court for a hearing on the transfer. 4. EMERGENCY TRANSFER. An emergency has made it impossible to provide prior notice or obtain prior written consent of the guardian. This notice of transfer is being provided for an emergency transfer immediately upon transfer to each of the persons and entities specified above who did not initiate the transfer, and to the court that ordered the protective placement within a reasonable time, not to exceed 48 hours from the time of transfer.  The individual under a protective placement, the individual’s guardian, the individual’s attorney, if any, or any other interested person has the right to file a petition with the court objecting to the emergency transfer. 5. This transfer will occur or has occurred at       (am) (pm) on       , 20    . TRANSFER FROM: (Placement unit Name, address, telephone number)       TRANSFER TO: (Placement unit Name, address, telephone number)       Original: Court Copies: Guardian. County department or agency with which it contracts. The Wisconsin Dept. of Health and Family Services. Protective Placement facility. Signature of Person or Entity Representative initiating transfer       Name Printed or Typed       Date GN-4340, 10/06 Notice of Transfer of Protective Placement §55.15(5), Wisconsin Statute This form shall not be modified. It may be supplemented with additional material.