Free Status Report to Court for Plan Compliance - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-20935 (Rev. 08/2008)

STATE OF WISCONSIN

STATUS REPORT TO COURT FOR PLAN COMPLIANCE
Use of form: Completion of this form meets the requirements of ss. 23.33(13)(e), 30.80(6)(d), 161.472 or 350.11(3)(d), Wis. Stats.

Name (Last, First, MI) Street or R.F.D. Name - Judge ORDERED BY COURT City

Birthdate State and Zip Code

Telephone Number County of Residence

MRV (motorized recreational vehicle) includes boats, snowmobiles and all terrain vehicles. Implied consent - MRV OWI - MRV OWI - Great bodily harm - MRV OWI - Homicide MRV Possession controlled substance

Address - Court (Street, City, Zip)

Case Number

Date - Conviction OWI - Injury - MRV

PLAN RECOMMENDATION Outpatient treatment Inpatient treatment or residential treatment Medical exam* *Facility Explain Regimen Regimen Psychiatric exam* Detoxification* Residential* Facility Facility Day treatment* Other*

DISPOSITION Compliance Noncompliance Remarks:

Date Agency Address

SIGNATURE Title

Ply 1 - Court

Ply 2 - Client

Ply 3 - Plan Provider

Ply 4 - Probation Agent

Ply 5 - Assessment Facility / 51.42 Staff