Fill and Sign the Wisconsin Protective Placement Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Order on Temporary Protective Placement or Protective Services       Date of Birth Case No.       A Statement of Emergency Protective Placement has been filed with a petition for: guardianship and protective placement protective placement of the individual and a preliminary hearing has been held to determine whether probable cause exists for protective placement. The court has considered testimony and other evidence presented and guardian ad litem’s recommendation. THE COURT FINDS: 1. Probable cause has not been established. 2. Probable cause that the individual needs protective placement and meets the standards for protective placement because:  The individual has a primary need for residential care and custody.  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;  As a result of developmental disabilities, degenerative brain disorder, serious and persistent mental illness, or 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.  The individual has a disability that is permanent or likely to be permanent. 3. Probable cause to believe that the individual meets the standards for protective services because:  the individual has been determined to be incompetent or is a minor alleged to be developmentally disabled and a petition for guardianship has been submitted, and  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. 4. Protective placement is not appropriate and the court elects to treat the Petition for Protective Placement as a Petition for Commitment under §51.20 or §51.45(13). 5. Other:       GN-4030, 10/06 Order on Temporary Protective Placement or Protective Services §§55.10(4) and 55.135, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Order on Temporary Protective Placement or Protective Services Page 2 of 2 Case No. THE COURT ORDERS: 1. These proceedings are dismissed and the individual is released. 2. Temporary protective placement of the individual for up to 30 days pending the hearing for a permanent protective placement. 3. The county department or agency with which it contracts under §55.02(2), Wisconsin Statutes, or its designee to provide protective services to the individual as may be required. 4. This Petition for Protective Placement to be treated as a Petition for Commitment under §51.20 or §51.45(13). 5. Other:       BY THE COURT: Circuit Court Judge/Court Commissioner       Name Printed or Typed       DateName of Attorney       Address       Telephone Number       Bar Number       GN-4030, 10/06 Order on Temporary Protective Placement or Protective Services §§55.10(4) and 55.135, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2