ME 921, 10/10 Statement of Petition for Review of Admission (24751.13, Wis. Stats.) 24751.13(4)(a), 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 THE CONDITION OF Name of Subject Date of Birth Statement of Petition For Review of Admission ( 247 51.13, Wis. Stats.) Case No. File this statement with the court within three (3) days after admission or an application for admission has been executed, whichever is sooner. The Court must either approve the admission within 5 after filing the Petition or hold a hearing within seven (7) days after admission or an application for admission has been executed. A copy of the application for admission and any relevant professional evaluations must be attached. Please print or type all information below. All blanks must be filled in. [Mental Health facility or Facility for Developmentally Disabled] and state: The minor, 14 years of age or older, refuses consent for admission. The minor, any age, exhibits, verbally and/or behaviorally, refusal of consent for admission. el, parent, or guardian requests a hearing. The minor has been hospitalized, psychiatrically, within past 120 days. The minor, who is developmentally disabled, is to be admitted for a stay exceeding 12 days. Date of admission: . Anticipated date of discharge: . City County State /Zipcode ame(s) and Street Address City County State /Zipcode and have reason to believe: 1. The minor is in need of psychiatric services, or services for developmental disability, alcoholism, or drug abuse based on the following facts: 2. Inpatient treatment in this inpatient facility is appropriate based on the following facts: 3. Inpatient care in this facility is the least restrictive setting consistent with the treatment needs of the minor based on the following considerations: American LegalNet, Inc. www.FormsWorkFlow.com ME 921, 10/10 Statement of Petition for Review of Admission (24751.13, Wis. Stats.) 24751.13(4)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 4. The minor has expressed his or her wishes regarding inpatient treatment at this facility through the following statement(s) and/or behaviors: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission /term expires: Signature of Treatment Director or Designee Name Printed or Typed Date DISTRIBUTION: 1. Court 2. Minor 3. Parent(s)/Legal Guardian(s) 4. Division of Disability and Elder Services American LegalNet, Inc. www.FormsWorkFlow.com