GN-4400, 05/18 Order on Petition to Modify Protective Placement or Protective Services 24724746.279 (2) and 55.16, 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 to Modify Protective Placement or Protective Services Case No. This matter is before the court on a Petition to Modify an Order for Protective Placement. Protective Services (other than an order for involuntary administration of psychotropic medication). Involuntary Administration of Psychotropic Medication. A hearing has not been held within the previous 6 months on Order for Protective Placement, Order for Protective Services or Transfer of Protective Placement. A hearing has been held on the Petition for Modification of Protective Placement or Protective Services within 21 days after filing the Petition, unless the ward, wardrdian ad litem, or attorney has requested an extension. The court has reviewed the testimony, reports, community plan (if applicable), other evidence presented and the report and recommendation of the guardian ad litem. THE COURT FINDS: 1. NOTICE AND JURISDICTION A. Notice was properly served. B. This court has jurisdiction over the subject matter and the ward. 2. PROTECTIVE PLACEMENT A. Continuation: The ward continues to meet the standards for protective placement under 24755.08 (1), Wis. Stats., and the protective placement is in the least restrictive environment and least restrictive manner consistent with the requirements of 24755.12 (3), (4), and (5), Wis. Stats., and protective placement is in the most integrated setting if the ward has a developmental disability and placement is in a nursing facility or intermediate care facility. B. Modification: The ward continues to meet the standards for protective placement under 24755.08 (1), Wis. Stats., but the protective placement is not in the least restrictive environment that is consistent with the requirements of 24755.12 (3), (4), and (5), Wis. Stats., or protective placement is not in the most integrated setting if the ward has a developmental disability and placement is in a nursing facility or intermediate care facility. C. Termination: The ward no longer meets the standards for protective placement under 24755.08 (1), Wis. Stats. The ward needs protective services and meets the standards for protective services as follows: American LegalNet, Inc. www.FormsWorkFlow.com GN-4400, 05/18 Order on Petition to Modify Protective Placement or Protective Services 24724746.279 (2) and 55.16, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 (1) The ward has been determined to be incompetent by a circuit court or is a minor who is alleged to have a developmental disability and on whose behalf a petition for guardianship has been submitted; and (2) As a result of a developmental disability, degenerative brain disorder, serious and persistent mental illness, or other like incapacities, the ward will incur a substantial risk of physical harm or deterioration or will present a substantial risk of harm to others if protective services are not provided. 3. PROTECTIVE SERVICES (Other than order for involuntary administration of psychotropic medication) A. Continuation: The ward continues to meet the standards for protective services under 24755.08 (2), Wis. Stats., and the current protective services are provided in the least restrictive manner that is consistent with the requirements of 24724755.12 (3), (4), and (5), Wis. Stats. B. Modification: The ward continues to meet the standards for protective services under 24755.08 (2), Wis. Stats., but the protective services for the ward are not provided in the least restrictive manner that is consistent with the requirements of 24755.12 (3), (4), and (5), Wis. Stats. C. Termination: The ward no longer meets the standards for protective services under 24755.08 (2), Wis. Stats. 4. Modification of the Order or Treatment Plan for involuntary administration of psychotropic medication for the ward would be in his or her best interests. THE COURT ORDERS: 1. PROTECTIVE PLACEMENT A. Continuation: Protective placement is continued in the facility in which the ward resides at the time of the hearing. B. Modification: The ward is transferred to a protective placement that is in the least restrictive environment consistent with the requirements of 24755.12 (3), (4), and (5), Wis. Stats., in the following specific facility: The county department of the wardto develop or recommend a protective placement that is in the least restrictive environment and arrange for the ward transfer to that protective placement within 60 days of the date of this Order. This time period is extended to permit development of a protective placement as follows: Protective services shall be provided. C. Termination: The protective placement is terminated. (1) The ward shall be transferred or discharged from his or her current residential facility within 60 days of this order. The county department shall assist the residential facility with discharge planning for the ward including planning for proper residential living arrangements and the necessary support services for the ward. (2) The ward may remain in the current facility, which is licensed for fewer than 16 beds. (3) The county department or agency with which is 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. 2. PROTECTIVE SERVICES A. Continuation: The Order for Protective Services is continued. The Order or treatment plan for involuntary administration of psychotropic medication for the ward is continued. American LegalNet, Inc. www.FormsWorkFlow.com GN-4400, 05/18 Order on Petition to Modify Protective Placement or Protective Services 24724746.279 (2) and 55.16, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 B. Modification: Protective services consistent with the requirements of 24755.06 (3), (4), and (5), Wis. Stats., shall be provided as follows: The Order or treatment plan for involuntary administration of psychotropic medication for the ward is modified as follows: . C. Termination: The Order for Protective Services is terminated for the following reason(s): . The Order or treatment plan for involuntary administration of psychotropic medication for the ward is terminated for the following reason(s): . 3. Other: THIS IS A FINAL ORDER FOR THE PURPOSE OF APPEAL. DISTRIBUTION: 1. Court 2. Individual/Ward 3. s Guardian 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