Statement Of Emergency Detention By Treatment Director {ME-902}

ME-902, 12/02 Statement of Emergency Detention by Treatment Director 24751.15, 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 Date of Birth Statement of Emergency Detention by Treatment Director Case No. 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. [Mental Health Facility] and state: or developmentally disabled. as set forth in 24751.15, 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: Dangerous Behavior: When: Where: Describe Behavior: See attached page Witnesses to the dangerous behavior: Name of Witness Telephone Address Relationship The subject was detained on [Date] , at [Time] am. pm. (Detention occurs when subject requests discharge.) City County State DISTRIBUTION: 1. Court 2. Subject with Notice of Rights Signature of Director or Designee Name Printed or Typed Telephone American LegalNet, Inc. www.FormsWorkFlow.com