Free Transfer Notice for Protective Placement - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care Division of Mental Health and Substance Abuse Services F-22605 (07/2008)

STATE OF WISCONSIN 55.06(9)(b) & (c) Wis Stats. HFS134.33 Wi Admin. Code

TRANSFER NOTICE FOR PROTECTIVE PLACEMENT
INSTRUCTIONS: Use this form to report the following moves of persons placed pursuant to Chapter 55 Wis. Stats: 1. If the client is moved to a more restrictive environment, even if it is within the same facility 2. If the transfer requires an increase in expenditures to the County 3. Any other transfers of clients placed pursuant to a Chapter 55 order The transfer need not be reported when it is to a hospital for general medical attention. It is assumed the guardian is notified as a matter of concern to keep the guardian informed. Name ­ Client (Last, First MI) ID Number

Transfer Date

,
In compliance with Wisconsin Statute 55.06(9)(b) and (c) and HFS 134.33 Wisconsin Administrative Code, you are notified that the above named individual will be or was transferred. Upon petition or request to a court by a guardian, ward or attorney or other interested person specifying objections to a transfer, the court shall order a hearing within 96 hours after filing of the request / petition, to determine whether there is probable cause to believe that the transfer is consistent with the requirements specified in Sec. 55.06(9)(a) Wis. Stats. and is necessary for the best interest of the ward. Yes Yes No No This transfer is to a more restrictive environment This transfer is to a locked unit Name, Address, Telephone Number of Facility / Unit Transferred To

Name, Address, Telephone Number of Facility / Unit Transferred From

Reason(s) For Transfer

SIGNATURE ­ Authorized Representative of Facility or Responsible County DISTRIBUTION ORIGINAL ­ Court Copies Guardian Responsible County Facility

Date Signed