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Physicians Report For Medication Or Treatment And Request For Hearing ME-917 - Wisconsin
| Physicians Report For Medication Or Treatment And Request For Hearing 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: : Physician's Report for Medication or Treatment and Request for JUDICIAL SUBPOENA Plaintiff(s) Hearing -against: Form Number: ME-917 : _______________________________________________________________________________ §51.61(1)(g), Wisconsin Statutes : Defendant(s) : ........ ......... .. ... Benchbook. Reference: . . . . . . . .MH. 2-17. . . . . . . . . . . . . . . . . . . . . . Statutory Reference: Purpose of Form: To allow corporation counsel to request a hearing to determine if the court should order medication and treatment. THE PEOPLE OF THE STATE OF NEW YORK Report section by physician and Request by the corporation counsel. Original to Court, copies to subject, subject's counsel, corporation counsel, mental health treatment providers and other interested persons. ME-918 Who Completes It: TO Distribution of Form: GREETINGS: Accompanying Forms: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before New Form/Modification: Modification, last update 06/00. , the Honorable at the Court located at County of Modifications: Reformatted to include report of physician and request for hearing by the in room , on the day of , 20 , at o'clock in the noon, and at any recessed corporation counsel. Changed form title. Removed order for hearing or adjourned date, to testify and give evidence as a witness in this action on the part of the section from this form and created a new form for order. See ME-918, Order for Hearing on Medication or Treatment. Comments: This form subpoena is punishable a a contempt of court and or after a Your failure to comply with thiswould be used at or after asfinding of probable causewill make you liable to the party on whose behalf this final commitment order. a maximum penalty of $50 and all damages sustained as a subpoena was issued for result of your failure to comply. About this form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office andof the Witness, Honorable , one of the Justices a Court in County, mandate of the Wisconsin 20 day of , Judicial Conference. 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 (Attorney must sign above and type name below) altered. Attorney(s) for Office and P.O. Address Date: 12/16/00 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 : Calendar No. COUNTY : JUDICIAL SUBPOENA Plaintiff(s) Physician's Report for Medication or Treatment : and Request for Hearing Case No. -againstName of Subject : : Date of Birth Report of Physician . . . . . . . physician . . . . . . . . . . . . . . . . . . . . . . of the subject I am a licensed . . . . . . . . .and. based .upon. my. examination . . . . . . . . . . . .individual, I state: 1. The subject is mentally ill, drug dependent, alcoholic, or developmentally disabled. 2. The subject needs medication or OF NEW YORK THE PEOPLE OF THE STATE treatment that would be therapeutic. 3. The medication or treatment will not unreasonably impair the subject's ability to prepare for and participate in TO future court proceedings. 4. I have explained to the subject the advantages and disadvantages and alternatives to accepting medication or treatment. Due to the subject's condition, the subject is incapable of expressing an understanding of the GREETINGS: 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 excuses being accept or refuse medicationyou attend before WE COMMAND YOU, that all business and to whether to laid aside, you and each of or treatment, with the result being that the subject is not competent to refuse medication or treatment due to his , the Honorable at the Court or her condition. located at County of Defendant(s) : 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 Signature of Physician 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 Phone Number Date result of your failure to comply. Witness, Honorable Court in County, Name of Facility Name Printed or Typed Request for Hearing day of , 20 , one of the Justices of the 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. (Attorney must sign above and type name below) Signature of Corporation Counsel Attorney(s) for Date Name of Corporation Counsel Address Office and P.O. Address Bar Number Telephone Number ME-917, 12/02 Physician's Report for Medication or Treatment and Request for Hearing Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: §51.61(1)(g), Wisconsin Statutes American LegalNet, Inc. www.USCourtForms.com This form shall not be modified. It may be supplemented with additional material.
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