Fill and Sign the Wisconsin Petition Protective Placement Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Petition for Modification of Order for 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 and Family Services. the county department that placed the individual or provided the protective services under an order of the court. an agency with which the county department contracts under §55.02(2). an interested person:       2. There has has not been a hearing held 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 within the previous 6 months . MODIFICATION OF ORDER FOR PROTECTIVE PLACEMENT. 3. This individual is currently placed in: Name of facility:       Address of facility:       4. The protective placement: is not in the least restrictive environment because protective placement:  is 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.  is not consistent with the factors required to be considered by the county department in 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 in 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 as 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 the 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.       GN-4380 01/07 Petition for Modification of Order for Protective Placement or Protective Services §§55.12(3)(4) and (5) and 55.16, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Petition for Modification of Order for Protective Placement or Protective Services Page 2 of 2 Case No. MODIFICATION OF ORDER FOR PROTECTIVE SERVICES. 6. Protective 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 medication 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 THAT 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 protective services. 6. 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-4380, 01/07 Petition for Modification of Order for Protective Placement or Protective Services §§55.12(3)(4) and (5) and 55.16, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2