Free Court Ordered Assessment and Plan Report - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-20934 (Rev. 08/2008)

STATE OF WISCONSIN

COURT ORDERED ASSESSMENT AND PLAN REPORT
Use of form: Completion of this form meets the requirements of s. 23.33(13)(e), 30.80(6)(d), 961.472, or 350.11(3)(d), Wis. Stats. FROM: Judge Address - Court: (Street, City, State, Zip Code) CLIENT INFORMATION Name - Client (Last, First, MI) Address (Street, City, State, Zip Code) ARREST / CONVICTION INFORMATION Date of Arrest Date of Conviction Birthdate (mm/dd/yyyy) Occupation Telephone Number Court:

County of Residence

Case Number

Offense First

Second

Third or more

Note: Motorized Recreational Vehicle (MRV) includes boats, snowmobiles and all-terrain vehicles. Implied Consent Refusal - MRV Intoxicated Great Bodily Harm - MRV Blood alcohol concentration: Operating While Intoxicated - MRV Intoxicated Homicide - MRV and / or Intoxicated Injury - MRV Possession of controlled substance Controlled substance: ASSESSMENT FINDINGS Note: "Substance" includes alcohol or controlled substances. Check appropriate box below. Did not complete assessment - Reason: Irresponsible substance use Substance dependency Irresponsible substance use - borderline Substance dependency in remission Suspected substance dependency Check substance use pattern and chronicity when the assessment finding is suspected dependency, dependency or borderline. Primary substance - Specify: Pattern: Intermittent Chronicity: Early Recurrent Moderately advanced Secondary substance(s) - Specify: Steady Far advanced Physiological, behavioral, psychological and / or attitudinal symptoms identified - Specify below.

Assessment instrument used: WAID Other - Identify: COMPLETE F-20934A FORM

AUTHORIZATION FOR RELEASE OF INFORMATION
I, (Name - Client) the recommended plan administered by of the (Name - Person completing assessment. Include title / certification.) , located at (Name - Assessment Facility) , and all status, treatment and attendance records (Address - Assessment Facility) (Street, City, State, Zip Code) , hereby consent to the release of the results of this assessment and

and information required prior to the expiration of this release to the staff of the county department under s. 51.42; the referring court and / or my probation agency and the plan provider(s) of my choice: The purpose for this disclosure is to aid in determining compliance with the court order for assessment and determination of any need for treatment. I further authorize the person / facility administering the assessment to follow-up and verify my compliance with any treatment plan. I understand that I may withdraw my consent at any time, prior to the expiration of this release except where revocation is prohibited according to s. 2.39, 42 CFR. SIGNATURE - Parent or Guardian (if client is under age 18) Release Date (mm/dd/yyyy) Date Signed Release Expiration Date (mm/dd/yyyy) Distribution: Original ­ Court SIGNATURE - Client Date Signed

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