CR-205, 02/17 Order for Competency Examination by DHS 247971.14, 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 State of Wisconsin, Plaintiff - vs - Name Date of Birth Order for Competency Examination by Department of Health Services Case No. Telephone Number Address Present Location THE COURT FINDS: 1. The defendant has been A. char ged with the following crime(s) an d probable cause has been found: B. found guilty of the following crime(s): Crime(s) (Attach copy of Complaint and Information for examiner.) Wis. Statute(s) Violated Date(s) Committed 2. Additional information or concerns, if any: THE COURT ORDERS: 1. The defendant shall submit to an examination of his or her competency to proceed. 2. The examination shall be conducted by the Department of Health Services (DHS), which shall determine where the examination will be conducted, who will conduct the examination and whether the examination will be conducted on an outpatient or inpatient basis. Outpatient examination shall be conducted in a jail or a locked unit of a facility unless the defendant is not in custody. 3. If an inpatient examination is necessary, unless the defe ndant is not in custody, the sheriff shall: Arrange for the transportation of the defendant to the examining facility within 48 hours after notification. American LegalNet, Inc. www.FormsWorkFlow.com CR-205, 02/17 Order for Competency Examination by DHS 247971.14, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 Return the defendant to the jail within 48 hours, after receiving notice from the examining facility that the examination has been completed. 4. , Wis. Stats. 5. The examination shall be completed and a report filed within: 15 days from the date of admission for an inpatient examination. 30 days from the date of this order for an outpatient examination. 6. ursuant to 247971.14(3), Wis. Stat s ., and the competency of the defendant to refuse medication. 7. A hearing will be held on [Date] , at [Time] a.m. p.m. before court official , or such other time as set by the court. 8. Other: Name of District Attorney Name of Defense Attorney Phone Number Fax Number Phone Number Fax Number Address of District Attorney Address of Defense Attorney DISTRIBUTION: 1. Court 2. District Attorney 3. Defendant/counsel 4. Examiner/facility 5. Sheriff (if an inpatient exam) American LegalNet, Inc. www.FormsWorkFlow.com