PROBATE COURT OF ___________________________COUNTY, OHIO _______________________________, JUDGE IN THE MATTER OF __________________________________________, AN ADULT CASE NO. _______________________ PETITION FOR EMERGENCY PROTECTIVE SERVICES [R.C. 5101.69] 1. Petitioner, _____________________________, is an authorized provider of adult protective Services pursuant to R.C. 5101.60, et seq. and has received a report that the above named Adult is in need of protective services. 2. The Adult, _____________________________, residing at _______________________ ______________________________________is ________years of age, with a date of birth of ___________, is alleged to be an incapacitated person and an emergency exists. 3. The specific facts alleging the nature of the emergency are: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 4. The proposed emergency protective services including placement, if applicable, are: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5. The Adult and the following persons are required to receive notice 24 hours prior to the hearing pursuant to R.C. 5101.69: Name Address Relationship to Adult ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ FORM 23.2 ­ PETITION FOR EMERGENCY PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO.__________________________ 6. (Complete if applicable) Petitioner requests a waiver of the 24 hour notice requirement because: a.) Immediate and irreparable physical harm to the Adult or others will result from the 24 hour delay. Explain:_______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ and b.) Reasonable attempts have been made to notify the above listed individuals, if any, if their whereabouts are known. Explain:____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7. The Adult has not consented and there is no person authorized by law or court order available or willing to give consent to the emergency protective services. WHEREFORE, the Petitioner requests the Court to authorize the implementation of the proposed emergency protective services and for such other relief as may be equitable. ______________________County Department of Job and Family Services _______________________________ Attorney By:_________________________________ _______________________________ Address ____________________________________ Title _______________________________ _______________________________ Phone Number (including area code) ____________________________________ Address ____________________________________ ____________________________________ Phone Number (including area code) _______________________________ Registration No. _______________________________ E-mail ____________________________________ E-mail Print Form FORM 23.2 ­ PETITION FOR EMERGENCY PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com