Free Court Order for Assessment - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-20933 (Rev. 08/2008)

STATE OF WISCONSIN

COURT ORDER FOR ASSESSMENT
Use of form: Completion of this form meets the requirements of Wisconsin Statutes, s. 23.33(13)(e), 30.80(6)(d), 961.472 or 350.11(3)(d). Name (Last, First, MI) Address (Street or RFD, City, State, ZIP Code Date of Arrest (mm/dd/yyyy) Court of Conviction List BAC Level or Controlled Substance Birthdate (mm/dd/yyyy) Occupation County of Residence

Telephone Number Case Number

Date of Conviction (mm/dd/yyyy)

Address - Court (Street, City, State, Zip Code)

[Motorized Recreational Vehicles (MRV) includes boats, snowmobiles, and all terrain vehicles] Having been found guilty or having had an adverse finding for a violation requiring assessment, namely: (Check the appropriate statute.) Implied Consent Refusal: MRV s. 23.33 (4p)(e), 30.684(5), 350.104(5) Wisconsin Statutes .......................................................... a local ordinance in conformity therewith....................................................................................... Operating While Under the Influence: MRV s. 23.33(4)(c)(a), 30.681(1), 350.101(1) Wisconsin Statutes ......................................................... a local ordinance in conformity therewith....................................................................................... Causing Injury: MRV - s. 23.33(4c)(b), 30.681(2), or 350.101(1) Wisconsin Statutes........................ Causing Homicide: MRV - s. 940.09 Wisconsin Statutes................................................................... Causing Great Bodily Harm: MRV - s. 940.25 Wisconsin Statutes .................................................... Possession of Controlled Substance - s. 961.41(3g)(am), (c), or (d) Wisconsin Statutes. .................. You are hereby ordered by Judge Court, telephone in s. 51.45(2)(c), Wisconsin Statutes, if needed.

First

Offense Second Third or More

of the , to submit and comply with an assessment by an approved public treatment facility as defined development of a treatment plan recommendation, if needed, and treatment plan completion,

The purpose of the assessment is to examine your use of intoxicants including controlled substances. Based on the assessment findings, a treatment plan recommendation may be made. This order and referral shall also serve as notice to you encouraging your cooperation, and any non-compliance with the assessment or treatment plan (if needed) will be reported to this court. For any intoxicated motorized recreational vehicle violation, your failure to comply will result in the court's consideration of invoking contempt of court proceedings under Chapter 785. For a violation under the Controlled Substance Chapter, your failure to comply will limit this court's ability to determine whether treatment is appropriate and sentencing considerations should be made. The assessment facility's report on the assessment and any treatment recommendation plan will be submitted within 14 days to the staff of the county department under s. 51.42, the recommended plan provider, this court and / or the Probation Department when required, and yourself. You are hereby referred to: Name - Assessment Facility Address - Facility (Street, City, State, Zip Code Telephone Number

SIGNATURE - Court Official

Date Signed

I agree to contact the above-named assessment facility within 72 hours to set an appointment for the assessment. I am aware that a fee is charged and that I am responsible for appropriate payment. I understand that my failure to participate will result in the court's consideration of contempt of court proceedings or revising my sentence. I also understand that any information I divulge during this assessment is protected by federal (Title 42 CFR Part 2) and state confidentiality regulations and laws and may not be used as evidence in any further prosecution.

SIGNATURE - Defendant Information attached for assessment facility: Citation Complaint Accident report Police report Related offenses Driving record Other

Date Signed

Distribution: Original - Court

Copies - Client, Recommended plan provider, Probation Agent, Assessment facility / 51.42 staff