GN-4170, 05/18 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 Petition for Involuntary Administration of Psychotropic Medication Petition for Protective Services Case No. x-noneUNDER OATH, I STATE: x-none 1. I am interested as Wisconsin Department of Health Services. the county department, or an agency with which the county department contracts, responsible for protective placement and protective services this county. a guardian of the ward. an interested person: [Indicate relationship to ward] . Other: [Indicate relationship to ward] 2. This Petition is filed in the county in which the ward resides. is physically present due to extraordinary circumstances. Explain: Other: 3. The ward resides in County, State of , [Phone number] and the wardmailing address is [Street, City, State and Zip] . 4. The name and mailing address of the person(s) or institution with care and custody of the ward or a facility providing care to the ward, if any, is [Name] [Phone Number] and the mailing address is [Street, City, State and Zip] . Type of facility: nursing facility community based residential facility intermediate facility center for developmentally disabled Other: x-none Is this facility licensed for 16 or more beds? Yes No 5. The names and mailing addresses of all interested parties and all others entitled to notice are as follows: See attached NAME RELATIONSHIP MAILING ADDRESS [Street, City, State and Zip] 6. The ward , if married, does does not have children that are not of the current marriage. 7. The ward does does not have a current, valid Power of Attorney for Health Care activated. Health Care Agent Name Phone Number Mailing Address [Street] [City, State, Zip] 8. A Petition for Permanent Guardianship is filed with this Petition, or American LegalNet, Inc. www.FormsWorkFlow.com GN-4170, 05/18 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 was filed and a guardian was previously appointed in this county. in another county in this state. [Name of guardian and county where appointed] in another state [Name of guardian and state where appointed] and a separate Petition for Receipt and Acceptance of a Foreign Guardianship is filed with this Petition for Protective Services. 9. Protective services were previously ordered on [Date] and additional protective services including involuntary administration of psychotropic medication are requested. COMPLETE QUESTIONS 10 AND 1 1 ONLY IF THERE IS NOT A CURRENT ORDER FOR PROTECTIVE PLACEMENT OR PROTECTIVE SERVICES. 10. I am requesting protective services for the ward, based on personal knowledge of the ward, and I state: x-noneA. The ward is eligible for protective services because the ward has attained the age of 18. is alleged to have a developmental disability and has attained the age of 14. B. This is a Petition for adult Protective Services and is initiated not more than 6 months prior to the ward18th birthday at which the ward first becomes eligible for services. C. The ward was adjudicated incompetent in Wisconsin more than 12 months before the filing of this Petition for Protective Services and a court review is required of the finding of incompetency. D. The non-resident ward has a need for protective services and a separate Petition to Transfer a Foreign Guardianship was filed whether the ward is present in the state or not. E. A comprehensive evaluation by the appropriate board or designated agency is filed. will be filed. x-noneA copy of the comprehensive evaluation and any independent comprehensive evaluation will be provided to the wardPower of Attorney for Health Care, guardian ad litem, the ward and the wardat least 96 hours in advance of the hearing to determine protective services. x-none 11. A. The ward meets all of the standards for protective services in 24755.08(2), Wis. Stats., as follows: x-none 1) The ward was determined incompetent by a circuit court or is a minor who is alleged to be developmentally disabled and on whose behalf a Petition for Guardianship was submitted, and x-none2) As a result of 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 physical harm to others if protective services are not provided. B. The specific facts and details explaining how the ward meets the standards for protective services and needs protective services are as follows: See attached ANSWER REMAINING QUESTIONS FOR ALL REQUESTS FOR INVOLUNTARY ADMINISTRATION OF PSYCHOTROPIC MEDICATIONS. 12. A. A physician has prescribed psychotropic medication for the ward. B. The ward is not competent to refuse psychotropic medication. C. One of the following is true: 1) The ward refused to take psychotropic medication voluntarily. The reasons for the wardrefusal to take psychotropic medication voluntarily are as follows: See attached Reason for refusal is unknown. The following evidence shows that a reasonable number of documented attempts to administer psychotropic medication voluntarily using appropriate interventions that could reasonably be expected to increase the wardwas made and was unsuccessful: See attached 2) Attempting to administer psychotropic medication to the ward voluntarily is not feasible or is not in the best interests of the ward. The specific reasons are as follows: See attached American LegalNet, Inc. www.FormsWorkFlow.com GN-4170, 05/18 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 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 wardhistory of at least 2 episodes, one of which occurred within the previous 24 months, that indicate a pattern of overt activity, attempts, threats to act, or omissions that resulted from the ward 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)(b), Wis. Stats., or commitment ordered under 24751.20(13), Wis. Stats. The specific facts are as follows: See attached 2) Evidence that the ward meets one of the dangerousness criteria set forth in 24751.20(1)(a)2, a. through e, Wis. Stats., is as follows: See attached 13. REQUIRED ATTACHMENT. Included with this Petition is a written statement signed by a physician who has personal knowledge of the ward that provides general clinical information regarding the appropriate use of psychotropic medication for the wardand specific data that indicates that the wardnecessitates the use of psychotropic medication. x-noneI REQUEST THE COURT: x-none x-none1. Order a hearing on this Petition. x-none x-none2. Appoint a guardian ad litem. x-none x-none3. Make a referral for appointment of an attorney for the ward. x-none x-none 4. Make appropriate findings that the ward meets the standard for protective services for involuntary administration of psychotropic medication. 5. Other: x-none State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Petitioner Name Printed or Typed Street Address City, State, Zip Date x-none DISTRIBUTION: 1. Court 2. Individual/Ward 3. 4. Corporation Cou