Fill and Sign the With Order for Involuntary Form

STATE OF WISCONSIN, CIRCUIT COURT, IN THE MATTER OF Name COUNTY Amended Statement of Noncompliance with Order for Involuntary Administration of Psychotropic Medication Date of Birth Case No. UNDER OATH I STATE: 1. An Order for Involuntary Administration of Psychotropic Medication was issued by the Court on . 2. Upon information and belief, the ward is not in compliance with the Order because he or she refuses to take psychotropic medication as ordered under the treatment plan. A statement of facts which constitutes the basis for the noncompliance of the ward is as follows: 3. It is necessary for the ward to be transported to or another appropriate facility for forcible restraint for administration of psychotropic medication. I REQUEST THE COURT: Issue an order authorizing the sheriff or any other law enforcement agency in the county in which the ward is found or in which it is believed that the ward may be present to take the ward into custody and transport him or her to an appropriate facility for administration of psychotropic medication using forcible restraint, with consent of the guardian. State of County of Subscribed and sworn to before me on Signature – Corporation Counsel Name Printed or Typed Telephone Number Notary Public/Court Official Name Printed or Typed My commission/term expires: State of County of Subscribed and sworn to before me on Signature – Ward’s Guardian Name Printed or Typed Telephone Number Notary Public/Court Official Name Printed or Typed My commission/term expires: State of County of Subscribed and sworn to before me on Notary Public/Court Official Signature – Director or Designee of the County Department or Agency that has contracted to develop and administer the treatment plan Name Printed or Typed Telephone Number Name Printed or Typed My commission/term expires: GN-4210, 05/19 Statement of Noncompliance with Order for Involuntary Administration of Psychotropic Medication §55.14(9), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material.