Report of Examination (Physician, Psychiatrist and/or Psychologist) 24751.20, Wis. Stats. INSTRUCTIONS This report will be used in a legal proceeding to determine if this subject individual should be involu ntarily committed for treatment. This report must be received by the court at least 48 hours prior to the scheduled hearing, excluding Saturdays, Sundays and legal holidays. However, if this is a reexamination under 247 51.20(16) Wis. Stats. , the report must be received by the court at least 7 days prior to the scheduled hearing, excluding Saturdays, Sundays and legal holidays. Please answer the questions to the best of your ability to a reasonable degree of professional /medica l certainty. Any questions that you cannot a . Type or print your answers neatly . You may supplement this report with attachments. You must inform the subject individual of his/her rights as set forth in the Report of Ex amination prior to the examination. DEFINITIONS Mental Ill ness A substantial disorder of thought, mood, p erception, orientation or memory which grossly impairs judgment, behavior, capacity to recognize reality, or the ability to meet the ordinary demands of life , but does not include alcoholism . Drug Dependent An individual is drug dependent when the individual uses one or more drugs to the extent substantially disrupted. Developmental Disability A disability attributable to brain injury, cerebral palsy, epilepsy, autism, Prader - Willi syndrome, intellectual disability, or another neurological condition closely related to an intellectual disabilit y or requiring treatment similar to that required for individuals with an intellectual disability, which has continued or can be expected to continue indefinitely and constitutes a substantial handicap to the afflicted individual. "Developmental disability " does not include dementia that is primarily caused by degenerative brain disorder. (This Instruction Page should NOT be submitted to the Court) American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL COURT RECORD ME-941, 02/16 Report of Examination 24751.20, Wis. Stats. 24751.20, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 5 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name of Subject Individual Date of Birth Amended Report of Examination 247 51.20, Wis. Stats. Case No. Name of Examiner: Psychiatrist Psychologist Licensed Physician Date of Examination: Time spent with subject individual : Place of Examination: If you were unable to personally examine the subject individual, please explain: Collateral sources u sed as part of your examination Records: Interviews with others: Other: Brief History: [Report relevant social and medical history , including information from collateral sources ] Prior to the examination, d id you inform the subject individual : A. Of the nature and reasons for the examination? Yes No B. T hat t he examination was ordered by the Court? Yes No C. T hat statements made can be used as a basis for commitment ? Yes No D. Of t he right to remain silent during the course of the examination? Yes No E. That y ou are re quired to make a report to the Court even if he/she remains silent? Yes No Did the subject individual appear to understand his/her rights? Yes No American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL COURT RECORD ME-941, 02/16 Report of Examination 24751.20, Wis. Stats. 24751.20, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 5 3 . A. his/ her reaction to the examination, gener al appearance, motor behavior, facial expressions, voice and speech, affect and mood) B. Describe the subject individual ht content and processes: (C onsider presence of compulsions, depressive or manic trends , hallucinations , delusions , grandiosity, persecutory trends ) C. Describe the subject individual u m : (Orientation, memory, insight, judgment, abstract thin king , general fund of knowledge ) EXAMINATION 1. Psychotropic Medications A. What psychotropic medication and dosage [if any] is being administered to the subject individual? B. How does this medication affect the subject individual examination? 2. Statement A. Summarize any relevant information obtained from the subject individual pertaining to past history and present events: B. Summarize any relevant information obtained from the subject individual pertaining to the incidents leading to detention , or leadi ng to commitment if the subject individual is currently under a commitment order : American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL COURT RECORD ME-941, 02/16 Report of Examination 24751.20, Wis. Stats. 24751.20, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 5 4 . T he subject individual is Mentally Ill. Drug Dependent. Developmentally Disabled. None of the above . Explain (Include diagnosis , if any ) : 5. A. The subject individual is dangerous because he/she evidences one or more of the following: (1) A substantial probability of physical harm to himself/herself as manifested by evidence of recent threats of or attempts at suicide or serious bodily harm. (2) A substantial probability of physical harm to other subjects as manifested by evidence of recent homicidal or other violent behavior, or by evidence that others are placed in reasonable fear of violent behavior and serious physical harm to them, as evidenced by a recent overt act, attempt or threat to do serious physical harm. (3) Such impaired judgment, manifested by evid ence of a pattern of recent acts or omissions, that there is a substantial probability of physical impairment or injury to himself/herself or other individuals. (The probability of physical impairment or injury is not substantial if reasonable provision fo reasonable probability that the subject individual may be provided protective placement or protective services under Ch. 55. Food, shelter or other care provided to the subj ect individual who is substantially incapable of obtaining the care for himself or herself, by a person other than a available in the community.) (4) Behavior manifested by recent acts or omissions that, due to mental illness, the subject individual is unable to satisfy basic needs for nourishment, medical care, shelter or saf ety without prompt and adequate treatment so that a substantial probability exists that death, serious physical injury, serious physical debilitation or serious physical disease will imminently ensue unless the subject individual receives prompt and adequa te treatment for this mental illness. (No substantial protection is available in the community and there is a reasonable probability that the subject individual w ill avail himself or herself of these services, if the subject individual may be provided protective placement or protective services under Ch. 55. Food, shelter or other care provided to the subject individual who is substantially incapable of obtaining t he care for himself or herself, by a person other than a treatment facility, does not constitute reasonable provision for the subject (5) There is a substantial probability, as demonstrated by both the subject individual 's treatment history and the subject individual 's recent acts or omissions, that the subject individual need s care or treatment to prevent further disability or deterioration, and further, there exists a substantial probability that if left untreated, the subject individual will lack the services necessary for his/her health or safety, and will suffer severe men tal, emotional or physical harm that will result in loss of ability to function independently in the community or the loss of cognitive or volitional control over the subject individual 's thoughts or actions. There is a reasonable probability that the subj ect individual will not avail himself/herself of services in the community for care or treatment necessary to prevent the subject individual from suffering severe mental, emotional or physical harm, and the subject individual is not appropriate for protect ive placement or prot