PROBATE COURT OF ___________________________COUNTY, OHIO _______________________________, JUDGE IN THE MATTER OF __________________________________________, AN ADULT CASE NO. _______________________ PETITION FOR PROTECTIVE SERVICES [R.C. 5101.65] 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 ___________ and is alleged to be an incapacitated person subject to abuse, neglect, or exploitation. 3. The specific facts alleging the abuse, neglect, or exploitation are: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 4. The proposed protective service plan including the least restrictive placement, if applicable, is as follows: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5. The Adult and the following persons are required to receive notice pursuant to R.C. 5101.66: Name Address Relationship to Adult ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ FORM 23.0 – PETITION FOR PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO.__________________________ 6. The Adult has not consented and there is no person authorized by law or court order available to give consent to the protective services. WHEREFORE, the Petitioner requests the Court to authorize the implementation of the proposed protective services plan and for such other relief as may be equitable. ______________________County Department of Job and Family Services _______________________________ By:_________________________________ Attorney _______________________________ ____________________________________ Address Title _______________________________ ____________________________________ Address _______________________________ ____________________________________ Phone Number (including area code) _______________________________ ____________________________________ Registration No. Phone Number (including area code) _______________________________ ____________________________________ E-mail E-mail FORM 23.0 – PETITION FOR PROTECTIVE SERVICES Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com