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Petition For Examination (Fifth Standard) ME-913 - Wisconsin
|Petition For Examination (Fifth Standard) 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. Name of Form: : Calendar No. Petition for Examination (Fifth Standard Under : §51.20(1)(a)2.e.) JUDICIAL SUBPOENA Plaintiff(s) -againstME-913 : Form Number: Statutory Reference: Benchbook Reference: §51.20(1)(a)2.e, Wisconsin Statutes: MH 1-7 : Defendant(s) : . . . . . . of . . . . . ... .......... ......... ... Purpose . . .Form: . . . . . . . . . . .This.form initiates. involuntary.civil. commitment proceedings by 3 adult petitioners of an individual who is believed to be mentally ill, incompetent to refuse psychotropic medications, and deteriorating as a result of lack of treatment. THE PEOPLE OF THE STATE OF NEW YORK Who Completes It: TO This form must be completed by the county corporation counsel, and must be signed and sworn to be true by 3 adult persons, at least one of whom has personal knowledge of the conduct of the subject individual. Distribution of Form: GREETINGS: The original document must be filed by the corporation counsel with the probate court for the county where the individual is present or the county of the individual's legal residence. A copy must be provided to the WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before subject individual at the time he or she is taken into custody for detention , the Honorable at the Court at a treatment facility. An additional copy must be provided to the located at County of detention facility at the time of admission of the individual. 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 Accompanying Forms: Generally none, unless petitioner adds pages with additional factual allegations. New Form/Modification:comply with this subpoena is punishable as a contempt of court and will make you liable to Modification, last update 06/00. Your failure to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Modification: failure to comply. Reformatted and removed notification to attorney general. result of your Comments:Witness, Honorable , one of the Justices of the Court in County, day of , 20 About this form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. (Attorney must sign above and type name below) If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Attorney(s) for Office and P.O. Address Date: 12/16/02 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : STATE OF WISCONSIN, CIRCUIT COURT, IN THE MATTER OF THE CONDITION OF Index No. For Official Use : COUNTY Calendar No. Petition for :Examination JUDICIAL SUBPOENA Plaintiff(s) (Fifth Standard Under : §51.20(1)(a)2.e, Wis. Stats.) -againstName of Subject Case No. Date of Birth : : Under oath, we petition the court to examine the condition of the subject, who resides in at Defendant(s) : ...................................................... Address County , and allege that: a. The subject is mentally ill and a proper subject for treatment because: THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Attach , the Honorable at the Court additional page if necessary. b. There exists all of the following for the subject: at located County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed 1. The advantages and disadvantages of and alternatives to accepting a particular medication or treatment or adjournedrecently explained to the evidence as a witness in this action on the part of theand date, to testify and give subject on have been ; Date 2. Due to mental illness, the subject is incapable of expressing an understanding of the advantages and disadvantages of accepting medication or treatment and the alternatives available, or the subject is Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to substantially incapable of applying an understanding of the advantages and disadvantages and alternatives the his or on whose behalfillness in order to make an informed choice penalty of $50to accept or refuse party her own mental this subpoena was issued for a maximum as to whether and all damages sustained as a to result of your failure to comply. medication or treatment; and 3. There is Witness, Honorable a substantial probability, as demonstrated by both the subject's treatment history and the subject's , one of the Justices of the recent acts or omissions, that the subject needs care or treatment to prevent further disability or deterioration, Courtfurther, there exists a substantial probability that if ,left untreated the subject will lack the services in County, day of 20 and necessary for his or her health or safety, and will suffer severe mental, 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's thoughts or actions; and (Attorney must sign above and type name below) 4. There is a reasonable probability that the subject will not avail himself or herself of services in the community for care or treatment necessary to prevent the subject from suffering severe mental, emotional or physical harm, and the subject is not appropriate for protective placement under §55.06, Wisconsin Statues. Attorney(s) for c. The following petitioner(s) has personal knowledge of the conduct of the subject: Name Address Telephone Relationship to Subject 1) 2) 3) Office and P.O. Address ME-913, 12/02 Petition for Examination (Fifth Standard Under §51.20(1)(a)2.e, Wis. Stats.) Page 1 of 2 This form shall not be modified. It may be supplemented with additional material. American LegalNet, Inc. www.USCourtForms.com Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: §51.20(1)(a)2.e, Wisconsin Statutes COURT COUNTY . . . . . . . . . . . .OF. . . .