JC-1660, 02/17 Order for Temporary Physical Custody Expectant Mother and Unborn Child 24748.213 and 48.133, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF J. Doe, an unborn child, and Date of Birth Order for Temporary Physical Custody - Expectant Mother and Unborn Child Case No. A hearing for temporary physical custody was held on [Date] , which is the effective date of this Order. THE COURT FINDS: 1. It has jurisdiction over the expectant mother and unborn child. 2. There is probable cause to believe that the expectant mother habitually lacks self-control in the use of alcohol beverages, controlled substances or controlled substance analogs, exhibited to a severe degree, to the extent that there is 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 unborn child, when born, in this matter would not be subject to or it is undetermined whether the unborn child would be subject to the Indian Child Welfare Act. 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. THE COURT ORDERS: 1. The adult expectant mother is held in custody A. in-home at . B. out-of-home at . 2. Other conditions of custody: 3. The adult expectant mother shall contribute toward the expenses of custody/services in the amount of $ . to be determined by [Agency] . 4. Transportation to the placement and any return to court shall be provided by . 5. The next hearing is [Date] at [Time] a.m. p.m. American LegalNet, Inc. www.FormsWorkFlow.com JC-1660, 02/17 Order for Temporary Physical Custody Expectant Mother and Unborn Child 24748.213 and 48.133, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 6. Other: Name and address of placement: 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. American LegalNet, Inc. www.FormsWorkFlow.com