Free Admission to Caseload - Revocation - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-25904 (07/2008)

STATE OF WISCONSIN

ADMISSION TO CASELOAD ­ REVOCATION
Completion of this form is required by the DMHSAS Conditional Release Program. Information will be used to determine client profile, quality assurance, recidivism rates and alternatives to recidivism. Name - Regional Provider Name ­ Client (Last, First MI) Diagnosis:

Name ­ Case Manager (Last, First MI) Name ­ Parole Agent (Last, First MI) Name ­ Defense Attorney (Last, First MI)

Name ­ Court Name ­ Judge (Last, First MI) Name ­ District Attorney (Last, First MI)

List treatment / support persons involved in client's care ( i.e., therapist / counselor, vocational rehabilitation, group home contact etc.) and average number of contacts with each listed 30 days prior to revocation. No. of Name Title Contacts

List support persons who impact on the client's life (i.e. parents, significant friends, partner, mentor, spouse, children) Name Relationship

Reason for return to institution care

Treatment History (briefly list facility / provider beginning and end dates) Facility / Provider

Begin Date

End Date

Release Origin Employment Status MMHI WMHI Direct Court Sheltered Maximum Competitive Medium Medium Part Time Minimum Minimum Full Time How does the client spend his / her day? (general / typical day ­ activities, contacts, etc.)

Length of time at MHI prior to conditional release Length of time on conditional release prior to revocation

Adjustment to Treatment

Significant Life Events (Recent, and / or dates of past events that may impact on mental health

Attachments (Check if attached)

Demographics ­ Regional Provider Face Sheet Current Individual Service Plan Statement of of Probable Cause

Criminal History (CIB ) Client's perception of reasons for revocation