PROBATE COURT OF ___________________________COUNTY, OHIO _______________________________, JUDGE IN THE MATTER OF __________________________________________, AN ADULT CASE NO. _______________________ PETITION FOR TEMPORARY RESTRAINING ORDER TO PREVENT INTERFERENCE WITH THE PROVISION OF PROTECTIVE SERVICES TO AN ADULT [R.C. 5101.68] 1. The above-named Adult is in need of protective services for the following reasons: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. The Adult has consented to the protective services. 3. The Respondent (Name and Address): _____________________________________________________________________________ _____________________________________________________________________________ has interfered with the provision of these services in the following manner: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. Unless Respondent is restrained, Petitioner will be unable to provide protective services in accordance with Chapter 5101. of the Revised Code. WHEREFORE, the Petitioner requests the Court to issue an order restraining Respondent from interfering with the provision of protective services to the Adult and such further 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 23.6 – PETITION FOR TEMPORARY RESTRAINING ORDER TO PREVENT INTERFERENCE WITH THE PROVISION OF PROTECTIVE SERVICES TO AN ADULT Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com