Temporary Physical Custody Request (Chapter 938)

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Temporary Physical Custody Request

(Chapter 938)

Referring Agency Case Number


Intake Case Number


Court Case Number


Requesting Agency Complete

Juvenile's Name (Last, First, Middle)


 African American  Asian or Pacific Islander

 American Indian or Alaskan Native

 Hispanic  Caucasian

 Unknown  Other

Date of Birth


 Male  Female

Juvenile's Address


If American Indian or Alaskan Native, list tribe:


Telephone Number


Why was juvenile taken into custody? (§ 938.19)


 Order by judge

 Criminal act


 Juvenile suffering from illness, injury or other danger

 Violation of terms of court-ordered supervision

 Violation of conditions of temporary custody order

 Violation of civil law or ordinance

 Unexcused absence from school

County of Residence


Father's Name and Address


Legal Status:  Alleged  Adjudicated  Presumed

Date of Birth


Home Telephone Number


Work Telephone Number


Mother's Name and Address


Date of Birth


Home Telephone Number


Work Telephone Number


Legal Guardian's Name and Address


Date of Birth


Home Telephone Number


Work Telephone Number


Date and Time Taken Into Custody


Taken Into Custody By




The parents notified by referring party?

 Yes (Date and Time)



Additional information on notice:      

Why was juvenile not released?      

Supporting facts of reason why juvenile was taken into physical custody (§938.20(3)):  See attachment


Copy provided to juvenile, if age 10 or over:  Yes  No

Intake Worker Complete

Was juvenile notified of right to counsel and right against self-incrimination? (§938.20(7)(a))

 Yes  No

Were notice of custody decision and hearing rights provided? (§938.20(8))

Juvenile:  Yes, Date and Time:      


Mother  Yes, Date and Time:      


Father:  Yes, Date and Time:      


If no, what ongoing efforts have been made to notify?


Jurisdictional Basis:

 1. No Jurisdiction.

 2. Delinquency: §     

 3. JIPS (§938.13):  uncontrollable.  habitually truant from school.  school dropout.  habitually truant from home.

 delinquent act before age 10.  not responsible or not competent.

Custody Criteria: (§938.205)

 1. Juvenile will commit injury to person or property of others.

 2. Juvenile will:  cause injury to self.  be subject to injury by others.  run away or be taken away so as to be unavailable for further court proceedings.

 3. Parent, guardian, legal custodian or other responsible adult is:  neglecting  refusing  unable  unavailable to provide adequate supervision and care.

Intake Worker Complete

Placement Decision:

 1. Juvenile released.

 2. Nonsecure custody: (§938.207)

 a. At the home of a  parent.  relative.  guardian.  person not a relative.

 b. At licensed foster home, treatment foster home, or group home.

 c. At non-secure facility operated by a licensed child welfare agency.

 d. At licensed private or public shelter care facility (including holdover room).

 e. At hospital or physician's office if the juvenile is believed to be suffering from a serious physical condition which requires either prompt diagnosis or prompt treatment.

 f. At licensed treatment facility approved by the county as the juvenile is believed to have a mental illness or developmental disability or to be drug dependent and exhibits conduct that constitutes a substantial probability of physical harm to the juvenile or to others, or a very substantial probability of physical impairment or injury to the juvenile exists due to the impaired judgment of the juvenile.

 g. At approved public treatment facility for emergency treatment as the juvenile is believed to be an intoxicated person who has threatened, attempted or inflicted physical harm on himself or herself or on another and is likely to inflict such physical harm unless committed, or is incapacitated by alcohol.

 h. At the county children’s home.

 3. Secure custody because: (§938.208)

 a. Juvenile has committed a delinquent act and there is a substantial risk of:  physical harm to another.  runaway.

 b. Juvenile has:  committed a felony delinquent act listed under §938.208(1)(a).  committed a felony delinquent act while in possession of a firearm.  possessed a short-barreled rifle, short-barreled shotgun, or handgun.

 c. Juvenile is a:  fugitive from another state  runaway from a juvenile correctional facility

and there has been no reasonable opportunity to return the juvenile.

 d. A protective order has been issued and the juvenile consents in writing to the placement.

 e. Juvenile has run away or committed a delinquent act while in nonsecure custody.

 f. Juvenile is alleged/adjudicated delinquent and is a runaway from another county and would run away from nonsecure placement.

 g. Juvenile is subject to the jurisdiction of the adult criminal court and is under 15 years of age.

 4. This is a secure custody placement in a jail because: (§938.209)

 a. No other approved juvenile detention facility is available.

 b. Juvenile is a substantial risk of physical harm to others in a juvenile detention facility.

Placement in the home is contrary to the welfare of the juvenile, due to:


Efforts made to prevent removal and return the child safely to the home include:


Name of Placement  Not disclosed to parent due to imminent danger




Telephone Number


Special precautions/information concerning juvenile/family


Signature of Intake Worker

Date and Time Custody Authorized


Date and Time of Custody Hearing


Date and Time of Release

JD-1710, 11/15 Temporary Physical Custody Request (Chapter 938) Chapter 938,Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.

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