JC-1661, 02/17 Dispositional Order Protection or Care of an Unborn Child 24724748.345 and 48.347, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF J. Doe, an unborn child, and Date of Birth Dispositional Order Protection or Care of an Unborn Child Case No. A Petition was filed with the court. A dispositional hearing was held on [Date] , which is the effective date of this Order. THE COURT FINDS: 1. The expectant mother habitually lacks self-control in the use of alcohol beverages, controlled substances or controlled substance analogs, exhibited to a severe degree. 2. There is a substantial risk that the physical health of the unborn child, and of the child when born, will be seriously affected or endangered unless the expectant mother receives prompt and adequate treatment for that habitual lack of self-control. 3. The provisions of the Indian Child Welfare Act do not apply. 4. As to the department or agency recommendation: A. The placement location recommended by the department or agency is adopted. OR B. After giving bona fide consideration to the recommendations of the department or agency and all parties, the placement location recommended is not adopted. 5. The Statement of Guardian ad Litem was filed. 6. Other: THE COURT ORDERS: 1. The unborn child and expectant mother are placed under court jurisdiction. 2. Placement of the expectant mother is A. in-home at . B. out-of-home at . If the mother successfully completes inpatient treatment services or requires removal from an inpatient treatment setting in order to receive medical care, pursuant to 24748.213(3)(a), Wis. Stats., the mother is ordered to cooperate with any requirements of an outpatient or aftercare AODA treatment program American LegalNet, Inc. www.FormsWorkFlow.com JC-1661, 02/17 Dispositional Order Protection or Care of an Unborn Child 24724748.345 and 48.347, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 recommended by the inpatient treatment facility; abstain from using any and all illegal substances and prescription drugs for which she does not have a prescription including participation in drug testing to demonstrate sobriety; comply with any anti-abuse prescription provided to her by a licensed provider; remain in contact with the County Social Services Department staff and cooperate with staff in providing information necessary to determine compliance with an AODA treatment program. 3. This order expires on [Date (Not to exceed one year)] . 4. Conditions of supervision or release: See attached 5. Specific services to be provided to expectant mother and family: See attached 6. Special treatment or care: 7. The adult expectant mother or parent(s), if the expectant mother is under 18, shall provide a statement of income, assets, debts, and living expenses to the county department or agency. The expectant mother/parent(s)/guardian shall contribute toward the expenses of custody/services in the amount of: $ . to be determined by [Agency] . 8. The appointment of the guardian ad litem for the unborn child terminates until further order of the court. is continued to allow the guardian ad litem to perform any duties under 24748.236(4), Wis. Stats. is continued for the following purpose(s): 9. The appointment of the attorney for the expectant mother Other: terminates until further order of the court. expectant mother Other: is continued through the term of this order. expectant mother Other: is continued for the following purposes: . 10. Other: NOTICE: If the expectant mother violates this order, she may be subject to proceedings for contempt of court, which may include being taken into custody. THIS IS A FINAL ORDER FOR THE PURPOSE OF APPEAL IF SIGNED BY A CIRCUIT COURT JUDGE. American LegalNet, Inc. www.FormsWorkFlow.com