GN-4180, 11/18 Order on Petition for Involuntary Administration of Psychotropic Medication 24755.14, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Order on Petition for Involuntary Administration of Psychotropic Medication Order for Protective Services Case No. A Petition for Involuntary Administration of Psychotropic Medication was filed and a hearing held on [Date] . After consideration of the reports and other documents on file, all factors required by the statutes, and such additional information presented; THE COURT FINDS: 1. JURISDICTION, VENUE, NOTICE, APPEARANCES AND EVALUATIONS TO COURT A. This court does does not have jurisdiction over the subject matter and the ward. B. This court is is not a proper venue. C. Notice was was not properly served. D. The ward is present. not present and the court accepts the waiver of presence by the guardian ad litem. E. The guardian ad litem did did not report the allegations in the Petition are true and involuntary administration of psychotropic medication is in the best interests of the ward pursuant to 24755.14(5), Wis. Stats. F. Additional evaluations are not necessary. 2. FOR PROTECTIVE SERVICES [when no order for protective services is in place] A. The ward does not meet the standards for protective services or need protective services. B. The ward needs protective services and meets the standards for protective services because: the ward was determined to be incompetent or is a minor alleged to have a developmental disability and a Petition for Guardianship was submitted, and as a result of a developmental disability, degenerative brain disorder, serious and persistent mental illness, other like incapacities, the ward will incur a substantial risk of physical harm or deterioration or will present a substantial risk of physical harm to others if protective services are not provided. 3. FOR INVOLUNTARY ADMINISTRATION OF PSYCHOTROPIC MEDICATION By clear and convincing evidence the allegations in the Petition are true: A. A physician has prescribed psychotropic medication for the ward. B. The ward is not competent to refuse psychotropic medication as such condition is defined by 24755.14(1)(b), Wis. Stats. C. One of the following is true and supported by the evidence: American LegalNet, Inc. www.FormsWorkFlow.com GN-4180, 11/18 Order on Petition for Involuntary Administration of Psychotropic Medication 24755.14, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 (1) The ward has refused to take psychotropic medication voluntarily. (2) Attempting to administer psychotropic medication to the ward voluntarily is not feasible or is not in the best interests of the ward. D. The wardwas prescribed is likely to be improved by administration of psychotropic medication and the ward is likely to respond positively to psychotropic medication. E. Unless psychotropic medication is administered involuntarily, the ward will incur a substantial probability of physical harm, impairment, injury, or debilitation or will present a substantial probability of physical harm to others. The substantial probability of physical harm, impairment, injury, or debilitation is evidenced by one of the following: (1) The ward(two) episodes, one of which has occurred within the previous 24 months, that indicate a pattern of overt activity, attempts, threats to act, or omissions that resulted from the ward to participate in treatment, including psychotropic medication, and that resulted in a finding of probable cause for commitment under 24751.20(7), Wis. Stats., a settlement agreement approved by a court under 24751.20(8)(bg), Wis. Stats., or commitment ordered under 24751.20(13), Wis. Stats. (2) Evidence that the ward meets one of the dangerousness criteria set forth in 24751.20(1)(a)2.a. through e, Wis. Stats. F. Psychotropic medication is necessary for treating the condition described in the written statement of the physician. G. All other requirements for ordering protective services were met. 4. . It is equitable wardand assets. 5. The ward or is committed to a mental institution. THE COURT ORDERS: The Petition is 1. DENIED for the following reason(s): . (If checked, skip to #4) 2. GRANTED as follows: A. FOR PROTECTIVE SERVICES The county department or agency with which it contracts under 24755.02(2), Wis. Stats., or its designee shall provide protective services to the ward in the least restrictive environment and in the least restrictive manner consistent with the needs of the ward and with the resources of the county department, including the limits of available state and federal funds, and county funds required to be appropriated to match state funds. B. FOR INVOLUNTARY ADMINISTRATION OF PSYCHOTROPIC MEDICATIONS (1) The ward of psychotropic medication to the ward. (2) Involuntary administration of psychotropic medication to the ward as a protective service. C. The nursing home or hospital or the county department or agency with which it contracts under 24755.02(2), Wis. Stats., or its designee shall develop a treatment plan for the ward specifying the protective services, including psychotropic medication as ordered by the treating physician, that the ward should receive. D. The ward must comply with the treatment plan pursuant to 24755.14(8)(b) and (9), Wis. Stats. 3. FIREARMS RESTRICTION The ward is prohibited from possessing any firearm. Federal law provides penalties for, and you may be prohibited from possessing, transporting, shipping, receiving, or purchasing a firearm, including, but not limited to, a rifle, shotgun, pistol, revolver, or ammunition, pursuant to 18 U.S.C. 921(a)(3) and (4) and 922(g)(4). This prohibition shall remain in effect until lifted by the court. American LegalNet, Inc. www.FormsWorkFlow.com GN-4180, 11/18 Order on Petition for Involuntary Administration of Psychotropic Medication 24755.14, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 A. Any firearm owned by subject shall be seized by . ward . Any person residing at the/these locations is required to cooperate with law enforcement attempts to seize firearms. Failure to cooperate may result in contempt sanctions. B. As an alternative to seizure, the following person is designated to store any firearm(s) until the firearm restriction order has been canceled: . C. ward is informed of the requirements and penalties under 247941.29, Wis. Stats., including imprisonment for up to 10 years, a fine not to exceed $25,000 or both. D. The court clerk shall notify the department of justice of the restriction unless the department was previously informed of a prohibition for this ward. 4. FEES AND COSTS A. Reasonable compensation of the guardian ad litem and wardfee shall be paid by the wardincome or assets, if sufficient. If the warddian ad litem shall be paid by the county of venue and the wardense or by the county of venue. B. nd costs shall be paid by the petitioner. from the ward C. The petitioner shall pay the compensation of the guardian ad litem and the ward attorney. D. Other: 5. Other: THIS IS A FINAL ORDER FOR THE PURPOSE OF APPEAL IF SIGNED BY A CIRCUIT COURT JUDGE. DISTRIBUTION: 1. Court 2. Individual/Ward 3. 4. Corporation Counsel 5. 6. Guardian ad litem 7. 8. Facility in which the Individual resides 9. County Department of Human Services/Social Worker American LegalNet, Inc. www.FormsWorkFlow.com