JC-1609, 11/17 Temporary Physical Custody Request Supplement (Chapter 48) 24724748.19 and 48.205, 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 I N THE INTEREST OF Name Temporary Physical Custody Request Supplement (Chapter 48) Case No. This document provides supplemental information to the Temporary Physical Custody Request filed in the above-captioned case on [Date] . Circumstances of the Maltreatment 1. Present Danger Threats ( C heck all that apply ) An immediate, significant, and clearly observable family condition that is occurring or in process of occurring at the point of contact with the family and will likely result in severe harm to the child. A. Maltreatment Child is being maltreated at the time of the report or initial contact. Severe to extreme maltreatment of child is suspected, obse rved or confirmed. Child has multiple or different kinds of injuries. Child has injuries to the face or head. Child has unexplained injuries. The maltreatment demonstrates bizarre cruelty (e.g., torture or extreme emotional abuse) . The maltreatment of several victims is suspected, observed or confirmed. The maltreatment appears premeditated. Dangerous (life threatening) livin g arrangements are present. B. Child (e.g., skewed and distorted) . Child is unsupervised and unable to care for self. Child needs medical attention. Child is profoundly fearful of the home situation or people within the home. C. Parent Parent is intoxicated (alcohol or other drugs) now or is consistently under the influence. Parent is out of control (mental illness or other significant lack of control). Parent is demonstrating bizarre behaviors (e.g., incoherent or inappropriate) . Parent is unable or unwilling to perform basic care. Parent is acting dange rous now or is described as dangerous. One or both parents overtly reject inter vention. D. Family The family may flee. The family hides the child. Child is subject to present/active domestic violence. Describe present danger threats: 2. Impending Danger Threats ( C heck all that apply ) A foreseeable state of danger in which a family behavior, attitude, motive, emotion or situation that can be anticipated to have severe effects on a child at any time in the near future and requires safety intervention. No adult in the home will perform parental duties and responsibilities. One or both parents/caregivers are violent. they will not/ cannot control t heir behavior. One or both parents/caregivers have extremely negative perceptions of the child. American LegalNet, Inc. www.FormsWorkFlow.com JC-1609, 11/17 Temporary Physical Custody Request Supplement (Chapter 48) 24724748.19 and 48.205, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 One or both parents/caregivers fear they will maltreat the child and/or request placement. One or both parents/caregivers lack parenting knowledge, skills, or mot ivation necessary to assure the child's basic needs are met. One or both parents/caregivers intend(ed) to seriously hurt the child. The child has exceptional needs which the parents/caregivers cannot or will not meet. The child is profoundly fear ful of the home situation or people within the home. Describe impending danger threats : 3. Child Vulnerab le to Danger Threats ( C heck all that apply ) Age (always includes ages 0 - 6) Physical disability Mental disabili ty Powerless Provoking behaviors Defenseless Non - Assertive Illness Invisible Describe how the child vulnerability relates to the identified danger threats : 4. protective capacities are currently insufficient to protect the child from the danger threats listed above: 5. Efforts to Prevent Removal 1. Describe e fforts to prevent removal or the emergency circumstances present: 2. An in - home plan will not work for this child, because: p lan is not sufficient . feasible . sustainable . c annot immediately control or manage threat of danger . n eeded people or services are not accessible or available when threat will be present . t he plan would rely on parental promises to control what has been assessed as out of control . Other: American LegalNet, Inc. www.FormsWorkFlow.com JC-1609, 11/17 Temporary Physical Custody Request Supplement (Chapter 48) 24724748.19 and 48.205, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 Other Information 1. Name and contact information of adult relative (s) or other adult individual(s) the parent requests the court to consider as placements for the child : (L ist at least 3 , if possible) A. B. C. 2. Describe immediate, interim family interaction plan between parents and child and siblings , if any: No family interaction plan because: 3. List any other conditions for the TPC order that the agency may/will request: 4. Siblings placed together: Yes No If no, describe why not : 5. Information the agency needs to obtain in order to completely assess the family: 6. Will the c hild be able to remain in the same daycare/school ? Yes No If no, then explain : WICWA 1. Is the child an Indian child? Yes No Undetermined (Explain: ) Name and address of tribe(s): 2. Was placement made in compliance with the order of placement preferences? Yes No If no, explain good cause or emergency conditions which necessitated departing fr om the placement preferences: Signature Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com