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Summary Hearing Findings And Order Continuing Protective Placement Order For Protective Services Form. This is a Wisconsin form and can be use in Circuit Court Statewide.
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Tags: Summary Hearing Findings And Order Continuing Protective Placement Order For Protective Services, GN-4120, Wisconsin Statewide, Circuit Court
FORM SUMMARY
Name of Form:
Summary Hearing Findings and Order Continuing
Protective Placement - Order for Protective Services
(Annual Review)
Form Number:
GN-4120
Statutory Reference:
§§46.279, 55.08(1)(b), 55.12(3),(4),(5) and 55.18(3), Wisconsin
Statutes
Benchbook Reference:
GA-3
Purpose of Form:
To order continued protective placement following summary
hearing.
Who completes it:
The court.
Distribution of Form:
Original – Court, Copies to: Individual; Individual’s Guardian;
Individual’s Legal Counsel, if any; Guardian ad Litem; Individual’s
agent under an activated power of attorney for healthcare, if any;
Facility in which the individual resided when petition for annual
review was filed; County Department of individual’s county of
residence under §55.18(1)(a) and County Department of individual’s
placement under §55.18(1m).
Accompanying Forms:
New Form/Modification:
Modification; last update 08/07.
Modifications:
Added Wamboldt language.
Comments:
This petition does not include annual review of orders for
psychotropic medications.
About this form:
This form is the product of the Wisconsin Records
Management Committee, a committee of the Director of
State Court’s Office and a mandate of the Wisconsin Judicial
Conference.
If you have additional information that does not change the
meaning of the form, attach it on a separate page. The form
itself shall not be altered.
Date: 04/24/2008
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For Official Use
COUNTY
STATE OF WISCONSIN, CIRCUIT COURT,
Amended
IN THE MATTER OF
Summary Hearing Findings
and Order Continuing
Protective Placement
Order for Protective Services
(Annual Review of
Protective Placement)
Case No.
Date of Birth
This matter is before the court on a Petition for Annual Review of Protective Placement. The court has considered
the information contained in the county department’s annual report of the review of the status of the individual,
Report and Recommendation of Guardian ad Litem (Annual Review) and any other relevant reports on the
individual’s condition and placement.
to order
additional information, and
not to order
The court has determined:
to appoint adversary counsel.
not to appoint
A request for a full hearing has been withdrawn.
The court has ordered a summary hearing and a summary hearing has been held.
The court has ordered a full hearing and a full hearing has been held.
THE COURT FINDS:
1. The individual continues to meet the standards for protective placement because:
• The individual has a primary need for residential care and custody;
• Except in the case of a minor that is age 14 or older, who is alleged to have a developmental disability, the
individual has either been adjudicated to be incompetent by a circuit court or a petition for guardianship has
been submitted on the minor’s behalf;
• As a result of:
a developmental disability
degenerative brain disorder
serious and persistent mental illness
other like incapacities
the individual is so totally incapable of providing for the individual’s own care or custody as to create a
substantial risk of serious harm to the individual or others. Serious harm may be evidenced by overt acts or
acts of omission.
• The individual has a disability that is permanent or likely to be permanent.
2. The current protective placement is:
the least restrictive environment consistent with the needs of the individual and 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 under the requirements of §55.12(3), (4) and (5).
not the least restrictive environment and:
individual needs to be transferred to a less restrictive environment consistent with the needs of
the individual and the requirements of §55.12(3), (4) and (5).
the county of residence needs to develop or recommend a protective placement that is the least
restrictive environment consistent with the needs of the individual and the requirements of
§55.12(3), (4) and (5).
individual needs to be transferred to a more restrictive environment consistent with the needs of
the individual and the requirements of §55.12(3), (4) and (5).
GN-4120, 04/08 Summary Hearing Findings and Order Continuing Protective Placement/Order for Protective Services (Annual Review of Protective Placement)
§§46.279, 55.08(1)(b), 55.12(3),(4),(5), and 55.18(3), Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
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Summary Hearing Findings and Order Continuing Protective Placement/Order for Protective Services (Annual Review of Protective Placement)
Page 2 of 2
Case No. _______________
3. The individual is determined to have a developmental disability and the most integrated setting appropriate for the
individual’s needs, and 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, is placement in:
a Center for developmentally disabled individuals.
a Nursing facility.
an Intermediate care facility.
a Non-institutional community placement.
Other:
THE COURT ORDERS:
1. Protective placement is continued in the facility in which the individual resides at the time of the hearing.
2. Transfer of the individual to a protective placement that is in the least restrictive environment consistent with the
individual’s needs and 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.
The county department or agency with which it contracts under §55.02(2), Wisconsin Statutes, or its
designee to provide protective services to the individual in the least restrictive environment and in the
least restrictive manner consistent with the needs of the individual and the requirements of §55.12(3), (4)
and (5).
3. The county department of residence shall develop or recommend a protective placement that is in the least
restrictive environment consistent with the needs of the individual and 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, and arrange for the individual’s transfer to that protective placement within 60 days after this court’s
order.
to permit the development of a protective placement.
The court is granting an extension until (date)
The county department or agency with which it contracts under §55.02(2), Wisconsin Statutes, or its
designee to provide protective services to the individual in the least restrictive environment and in the
least restrictive manner consistent with the needs of the individual and the requirements of §55.12(3), (4)
and (5).
4. Transfer of the individual with a developmental disability in accord with the plan for the most integrated setting
appropriate for the individual’s needs and consistent 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, to:
an intermediate facility.
a nursing facility.
a center for developmentally disabled.
.
Other:
a noninstitutional community setting.
THIS IS A FINAL JUDGMENT/ORDER FOR PURPOSES OF APPEAL.
BY THE COURT:
Circuit Court Judge/Court Commissioner
Name Printed or Typed
Date
Distribution:
1. Original - Court
2. Individual
3. Individual’s Guardian
4. Individual’s Legal Counsel, if any
5. Guardian ad Litem
6. Individual’s agent under an activated power of attorney for healthcare, if any
7. Facility in which the individual resided when petition for annual review was filed
8. County Department of individual’s county of residence under §55.18(1)(a)
9. County Department of individual’s placement under §55.18(1m)
GN-4120, 04/08 Summary Hearing Findings and Order Continuing Protective Placement/Order for Protective Services (Annual Review of Protective Placement)
§§46.279, 55.08(1)(b), 55.12(3),(4),(5), and 55.18(3), Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 2 of 2
American LegalNet, Inc.
www.FormsWorkflow.com
