Statement For Involuntary Medication Or Treatment {ME-943}

CONFIDENTIAL COURT RECORD ME-943, 02/16 Involuntary Medication and Treatment Information 24724751.20, 51.61(1)(g) and 51.67, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF THE CONDITION OF Name of Subject Individual Date of Birth Amended Statement for Involuntary Medication or Treatment Case No. Date of Examination: 1. Will medication or treatment have therapeutic value for the subject individual ? Yes No If yes, what medication or treatment is recommended ? 2. Will medication or treatment unreaso nably impair the ability of the subject individual to prepare for or participate in subsequent legal proce eding s? Yes No Explain: 3. Did you explain the advantages, disadvantages, and alternatives to the recommended medication or t reatment to the subject individual ? Yes No A. List the advantages explained: B. List the disadvantages explained : C. List the alternatives explained: 4. Is the subject individual in capable of expressing an understanding of the advantages, disadvantages and alternatives to accepting the recommended medication or treatment ? Yes No Explain: 5. Is the subject individual substantially in capable of applying an understanding of the advantages, disadvantages and alternatives t o his/her condition in order to make an info rmed choice as to whether to accept or refuse the recommended medication or treatment? Yes No Explain: 6. the cause of the subject s inability to expre ss or apply an understanding: Mental Illness Drug Dependency Developmental Disability Alcoholism Comments: DISTRIBUTION: 1. Court 2. Corporation Counsel Examiner Psychiatrist Physician Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com