Free Plan Recommendation - Wisconsin

File Size: 35.5 kB
Pages: 1
Date: August 14, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Word Count: 339 Words, 2,160 Characters
Page Size: Letter (8 1/2" x 11")

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


(Under Wis. Stats. s. 23.33 (13)(e), 961.472, or 350.11 (3)(d))

Name - Client On the basis of my assessment concerning this client's use of I recommend: Treatment not recommended - Remarks: Outpatient treatment - Describe regimen and duration: Inpatient treatment or residential treatment - Describe regimen and duration: Medical exam Psychiatric exam Detoxification Explain need and describe regimen and duration: alcohol

Birthdate (mm/dd/yyyy) other drugs, and / or

Case Number

controlled substances,

Transitional living

Day care treatment


The recommended treatment plan period may extend until: The court or its agent will be notified if the client fails to comply with the order. Copies of this report are going to the staff of the county department under s. 51.42; the referring court and / or the probation agent; the recommended plan provider of choice, and the client. Name - Provider City Telephone Number

I understand the recommendations made above and agree to comply. I have been informed as to the fee provisions under par. 46.03 (18)(f) or (fm), Wisconsin Statutes, for assessment and treatment plan costs. I agree to set an appointment with my chosen plan provider within 72 hours unless a court order is required. I further understand that if I fail to comply with the assessment or treatment plan for a motorized recreational vehicle (MRV) violation, the court may instigate contempt of court proceedings. If I fail to comply with assessment or any treatment plan to which I agree and the court orders for a Controlled Substance violation, I understand that the court will consider revision of my sentence. Release of information expires: SIGNATURE - Client SIGNATURE - Consenting Treatment Facility (optional for controlled substance chapter violations) SIGNATURE - Assessor Title / Certification Date Signed (mm/dd/yyyy) Date Signed (mm/dd/yyyy) Date Signed (mm/dd/yyyy)

Distribution: Original - Court Client Plan provider Probation agency Assessment facility / 51.42 staff