Fill and Sign the Wisconsin Protective Placement 497431052 Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Summary Hearing Findings and Order Continuing Protective Placement Order for Protective Services (Annual Review of Protective Placement)       Date of Birth Case No.       This matter is before the court on a Petition for Annual Review of Protective Placement. The court has ordered a summary hearing and a summary hearing has been held. The court has considered the information contained in the county department’s annual report of the review of the status of the individual, Report and Recommendation of Guardian ad Litem (Annual Review) and any other relevant reports on the individual’s condition and placement. The court has determined not to order to order additional information, and not to appoint to appoint adversary counsel. A request for a full due process hearing has been withdrawn. THE COURT FINDS: 1. The individual continues to meet 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 other like incapacities the individual is so totally incapable of providing for the individual’s own care or custody as to create a substantial risk of serious harm to the individual 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. 2. The current protective placement consistent with the needs of the individual and the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds, is: the least restrictive environment consistent with the needs of the individual and the requirements of §55.12(3), (4) and (5). not the least restrictive environment and: individual needs to be transferred to a less restrictive environment consistent with the needs of the individual and the requirements of §55.12(3), (4) and (5). the county of residence needs to develop or recommend a protective placement that is the least restrictive environment consistent with the needs of the individual and the requirements of §55.12(3), (4) and (5). individual needs to be transferred to a more restrictive environment consistent with the needs of the individual and the requirements of §55.12(3), (4) and (5). GN-4120, 10/06 Summary Hearing Findings and Order Continuing Protective Placement/Order for Protective Services (Annual Review of Protective Placement) §§46.279, 55.08(1)(b), 55.12(3),(4),(5), and 55.18(3), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 GN-4120 Summary Hearing Findings and Order Continuing Protective Placement/Order for Protective Services (Annual Review of Protective Placement) Page 2 of 2 Case No. 3. The individual is determined to have developmental disabilities and the most integrated setting appropriate for the individual’s needs, and the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds, is placement in: a Center for developmentally disabled individuals. a Nursing facility. an Intermediate care facility. a Non-institutional community placement. Other:       THE COURT ORDERS: 1. Protective placement is continued in the facility in which the individual resides at the time of the hearing. 2. Transfer of the individual to a protective placement that is in the least restrictive environment consistent with the individual’s needs and the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds. 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 in the least restrictive environment and in the least restrictive manner consistent with the needs of the individual and the requirements of §55.12(3), (4) and (5). 3. The county department of residence shall develop or recommend a protective placement that is in the least restrictive environment consistent with the needs of the individual and the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds, and arrange for the individual’s transfer to that protective placement within 60 days after this court’s order. The court is granting an extension until (date)       to permit the development of a protective placement . 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 in the least restrictive environment and in the least restrictive manner consistent with the needs of the individual and the requirements of §55.12(3), (4) and (5). 4. Transfer of the individual with developmental disabilities in accord with the plan for the most integrated setting appropriate for the individual’s needs and consistent with the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds, to: a center for developmentally disabled. a nursing facility. an intermediate facility. a noninstitutional community setting. Other:       . SEAL BY THE COURT: Circuit Court Judge/Court Commissioner       Name Printed or Typed       Date Distribution: 1. Original - Court 2. Individual 3. Individual’s Guardian 4. Individual’s Legal Counsel, if any 5. Guardian ad Litem 6. Individual’s agent under an activated power of attorney for healthcare, if any 7. Facility in which the individual resided when petition for annual review was filed 8. County Department of individual’s county of residence under §55.18(1)(a) 9. County Department of individual’s placement under §55.18(1m) GN-4120, 10/06 Summary Hearing Findings and Order Continuing Protective Placement/Order for Protective Services (Annual Review of Protective Placement) §§46.279, 55.08(1)(b), 55.12(3),(4),(5), and 55.18(3), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2