Fill and Sign the Wi Protective Placement 497431046 Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF             Amended Petition for Protective Placement Protective Services       Date of Birth Case No.       UNDER OATH, I STATE THAT: 1. I am interested as: the Wisconsin Department of Health and Family Services. the county department or an agency with which the county department contracts. the guardian. an interested person:       . 2. This petition is filed in: the county of residence of the individual. the county in which the individual is physically present. Other:       3. The residence of the individual is in       County, State of       , and the individual’s post-office address is:       . 4. I have exercised due diligence to locate all interested parties. The names and post office addresses of all interested parties and all others entitled to notice are as follows: See attached . NAME RELATIONSHIP POST-OFFICE ADDRESS                   5. The individual, if married, does does not have children not of the current marriage. 6. The individual: does does not have a current, valid financial durable power of attorney activated. Name, address and phone:       does does not have a current, valid power of attorney for health care activated. Name, address and phone:       does does not have other advance planning to avoid protective placement. If the above-named powers of attorney or advanced planning exist, protective placement is still necessary because:       . See attached . GN-4040, 04/07 Petition for Protective Placement/Protective Services §46.279, Chapter 54 and 55 , Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 Petition for Protective Placement/Protective Services Page 2 of 3 Case No. 7. A. A petition for permanent guardianship is being filed. B. A guardian has been appointed: in this county. in another county in this state (Name of guardian and county where appointed)       in another state (Name of guardian and state where appointed)       and a separate petition for receipt and acceptance of a foreign guardianship is being filed to accompany this petition. 8. The name and post-office address of the person or institution, if any, that has care and custody of the individual or the facility, if any, that is providing care to the individual is: Name:       Phone Number:       Post-office Address:       Type of facility: community based residential facility Is this facility licensed for 16 or more beds? Yes No intermediate facility center for developmentally disabled nursing facility Other:       9. I am requesting protective placement and/or protective services for the individual, based upon personal knowledge of the individual, and I state that: A. The individual is eligible for protective placement because the individual: has attained the age of 18. is alleged to be developmentally disabled and has attained the age of 14. B. A petition for adult protective placement is being initiated not more than 6 months prior to the individual’s birthday at which the individual first becomes eligible for placement. C. The individual has been adjudicated incompetent in Wisconsin more than 12 months before the filing of this petition for protective placement and/or protective services and a court review is required of the finding of incompetency. D. The non-resident individual has a need for protective placement and/or protective services and a separate petition to transfer a foreign guardianship has been filed whether the individual is present in the state or not. E. A comprehensive evaluation and community plan, if required, and recommendation for placement by the appropriate board or designated agency is being filed. will be filed. A copy of the comprehensive evaluation and any independent comprehensive evaluation will be provided to the individual’s guardian, agent under any activated health care power of attorney, guardian ad litem, the individual and the individual’s attorney at least 96 hours in advance of the hearing to determine protective placement or protective services. FOR PROTECTIVE PLACEMENT. 10. A. The individual needs protective placement and meets the standards for protective placement specified in §55.08 (1), Wisconsin Statutes as follows: 1. The individual has a primary need for residential care and custody. 2. Except in the case of a minor that is age 14 or older, who is alleged to be developmentally disabled, the individual has either been adjudicated to be incompetent by a circuit court or a petition for guardianship has been submitted on the minor’s behalf; 3. As a result of developmental disabilities degenerative brain disorder serious and persistent mental illness other like incapacities, the individual is so totally incapable of providing for his or her own care or custody as to create a substantial risk of serious harm to himself or herself or others. Serious harm may be evidenced by overt acts or acts of omission. 4. The individual has a disability that is permanent or likely to be permanent. GN-4040, 04/07 Petition for Protective Placement/Protective Services §46.279, Chapters 54 and 55 , Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 Petition for Protective Placement/Protective Services Page 3 of 3 Case No. B. The specific facts and details of how the individual meets the standards for protective placement and needs protective placement are as follows: See attached.       C. The individual is alleged to be developmentally disabled. D. The petitioner requests protective placement of the individual in the following facility:       or a like facility. E. A locked unit is necessary because:       F. This petition for protective placement is being filed prior to transfer of the individual directly from a hospital to a nursing home or community-based residential facility and the individual does does not verbally object to or otherwise actively protest the admission. FOR PROTECTIVE SERVICES. 11. A. The individual meets all of the standards as follows for protective services specified in §55.08(2), Wisconsin Statutes: 1. The individual has been determined incompetent by a circuit court or is a minor who is alleged to be developmentally disabled and on whose behalf a petition for guardianship has been submitted, and 2. As a result of developmental disabilities, degenerative brain disorder, serious and persistent mental illness, or other like incapacities, the individual will incur a substantial risk of physical harm or deterioration or will present a substantial risk of physical harm to others if protective services are not provided. B. The specific facts and details explaining how the individual meets the standards for protective services and needs protective services are as follows: See attached.       I REQUEST THAT THE COURT: 1. Order a hearing on this petition. 2. Make appropriate findings and order: protective placement of the individual. protective services for the individual. 3. Award appropriate fees and costs. Subscribed and sworn to before me on       Notary Public/Court Official My commission expires:       Signature of Petitioner       Name Printed or Typed       Address       Name of Attorney       Address       Telephone Number       Bar Number       GN-4040, 04/07 Petition for Protective Placement/Protective Services §46.279, Chapters 54 and 55 , Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3