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Statement Of Emergency Detention By Treatment Director ME-902 - Wisconsin
|Statement Of Emergency Detention By Treatment Director Form. This is a Wisconsin form and can be used in Medical Circuit Court Statewide .||
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COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. FORM SUMMARY : : Index No. Calendar No. Name of Form: Form Number: Statutory Reference: Benchbook Reference: Statement of Emergency Detention by Treatment Director : Plaintiff(s) JUDICIAL SUBPOENA ME-902 -against- : §51.15(10), Wisconsin Statutes : MH 1-9 Defendant(s) : : . . . . . . . . Form: ... .... ....... ......... .. Purpose. of . . . . . . . . . . . . . . . .This. form. initiates .involuntary. civil commitment proceedings by treatment director at an approved treatment facility (or his or her designee) of a patient of that facility who is believed to be mentally ill, developmentally disabled, or drug dependent and dangerous to THE PEOPLE OF THE STATE OF NEW YORK self or to others. Who Completes It: TO This form must be completed, signed, and filed by the treatment director (or designee) who detains the patient at the approved treatment facility. The original document must be filed by the treatment director (or GREETINGS: Distribution of Form: WE COMMAND YOU, that allwith the court having probate jurisdiction, for the county designee) business and excuses being laid aside, you and each of you attend before , the Honorable at the where the individual is present or theCourt of the individual's county located at County of legal residence as soon as possible after detention at the approved in room , on the day of , at o'clock noon, treatment facility. A20 copy ,must be providedin the patient atand at any recessed to the the or adjourned date, to testify and give evidence as a witness in this action on the part of the time of detention. A second copy should be retained by the treatment facility. Your Forms: Accompanyingfailure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. New Form/Modification: Modification, last update 06/00. Witness, Honorable Reformatted and updated statute references.one of the Justices offor , Added check box the Modification: Court in County, attaching of day additional pages. , 20 Comments: About this form: None (Attorney must sign above and type name below) This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and Attorney(s) for a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on aand P.O. Address The form Office separate page. itself shall not be altered. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com Date: 12/16/02 STATE OF WISCONSIN, CIRCUIT COURT, IN THE MATTER OF THE CONDITION OF COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. For Official Use COUNTY Calendar No. Statement of Emergency Detention : by Director Plaintiff(s) Treatment JUDICIAL SUBPOENA Case No. Name of Subject -againstDate of Birth : : · File this statement with the detention facility and court immediately. A probable cause hearing must be held within 72 hours of detention. : · Please print or type all information below. All blanks must be filled in. I am a treatment. director/treatment .director's .designee .of . . . . . . . . . . . . . . ....... .............. ....... ....... . Mental Health Facility and state: · The subject is mentally ill, drug dependent, or developmentally disabled. · The subject evidences behavior which constitutes a substantial probability of physical harm to self or to others, as THE PEOPLE OF THE STATE OF NEW YORK set forth in §51.15, Wisconsin Statutes. My belief is based on specific and recent dangerous acts, attempts, threats or omissions by the subject as observed by me or reliably reported to me as stated below: TO Dangerous Behavior: When: Where: Defendant(s) : GREETINGS: WE Describe Behavior: COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. See attached page. Witnesses to the dangerous behavior: Witness, Honorable Court in Name of Witness County, day of Telephone , 20 Address , one of the Justices of the Relationship (Attorney must sign above and type name below) Attorney(s) for The subject was detained on when subject requests discharge.) Subject's Street Address Date , at Time am. City County Office and P.O. Address pm. (Detention occurs State Signature of Director or Designee Distribution: 1. Court Original 2. Subject with Notice of Rights Name Printed or Typed ME-902, 12/02 Statement of Emergency Detention by Treatment Director Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Telephone §51.15, Wisconsin Statutes American LegalNet, Inc. www.USCourtForms.com This form shall not be modified. It may be supplemented with additional material.