GN-4380, 05/18 Petition to Modify Protective Placement or Protective Services 24724755.12(3)(4) and (5) and 55.16, 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 IN THE MATTER OF Name Date of Birth Amended Petition to Modify Protective Placement or Protective Services Case No. UNDER OATH, I STATE: 1. I am interested as the ward under protective placement or receiving protective services. the ward the ward the Wisconsin Department of Health Services. the county department that placed the ward or provided the protective services under a court order. an agency with which the county department contracts under 24755.02(2), Wis. Stats. an interested person: 2. There has has not been a hearing held within the previous 6 months on a court ordered protective placement for the ward or on a Petition for court ordered protective services or transfer of protective placement with respect to the ward. MODIFICATION OF ORDER FOR PROTECTIVE PLACEMENT 3. The ward is currently placed at Name of facility Address of facility Name of Contact Person Phone Number of Contact Person 4. The protective placement is not in the least restrictive environment because protective placement: is not the least restrictive environment and the least restrictive manner that is consistent with the needs of the ward and with the resources of the county department. is not consistent with the factors required to be considered by the county department in providing protective placement. is not consistent with the required funding that the county is required to provide. in a facility with a higher level of restrictiveness would be: in the least restrictive environment and the least restrictive manner that is consistent with the needs of the ward and with the resources of the county department. consistent with the factors required to be considered by the county department in providing protective placement. consistent with the required funding that the county is required to provide. in a different facility with the same level of restrictiveness as the current placement would be more: consistent with the factors required to be considered by the county department in providing protective placement. consistent with the required funding that the county is required to provide for reasons unrelated to the level of restrictiveness. 5. The specific facts underlying the request for modification are as follows: See attached American LegalNet, Inc. www.FormsWorkFlow.com GN-4380, 05/18 Petition to Modify Protective Placement or Protective Services 24724755.12(3)(4) and (5) and 55.16, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 MODIFICATION OF ORDER FOR PROTECTIVE SERVICES 6. Protective services (other than involuntary administration of psychotropic medication) are not being provided in the least restrictive environment or manner because protective services: are not in the least restrictive environment and the least restrictive manner that is consistent with the needs of the ward and with the resources of the county department. are not consistent with the factors required to be considered by the county department in providing protective services. are not consistent with the required funding that the county is required to provide. 7. Modification of the order or treatment plan for involuntary administration of psychotropic medication for the ward would be in his or her best interests. 8. The specific facts underlying the request for modification are as follows: See attached I REQUEST THE COURT: 1. Order a hearing on this Petition. 2. Make appropriate findings as requested above. 3. Order modification of the protective placement for the ward that is consistent with the requirements for providing protective placement. 4. Order modification of the protective services for the ward that is consistent with the requirements for providing protective services. 5. Order modification of the order or treatment plan for involuntary administration of psychotropic medication for the ward that is consistent with the requirements for providing protective services. 6. Award appropriate fees and costs. 7. Other: 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 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