ME- 24751.61(1)(g), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF THE CONDITION OF Name of Subject Date of Birth Medication or Treatment and Request for Hearing Case No. Report of Physician I am a licensed physician and based upon my examination of the subject individual, I state: 1. The subject is mentally ill, drug dependent, alcoholic, or developmentally disabled. 2. The subject needs medication or treatment that would be therapeutic. 3. court proceedings. 4. I have explained to the subject the advantages and disadvantages and alternatives to accepting medication or advantages and disadvantages and alternatives to accepting this particular medication or treatment, or is substantially incapable of applying an understanding of the advantages, disadvantages and alternatives to his or her condition in order to make an informed choice as to whether to accept or refuse medication or treatment, with the result being that the subject is not competent to refuse medication or treatment due to his or her condition. Name of Facility Phone Number Signature of Physician Name Printed or Typed Date Request for Hearing I request the court conduct a hearing at a date, time, and place set by the court, to determine whether the subject is competent to refuse medication or treatment and grant an appropriate order. Corporation Counsel Date Name of Corporation Counsel Address Telephone Number Bar Number American LegalNet, Inc. www.FormsWorkFlow.com