Eau Claire County Treatment Courts – Treatment Court Referral Form

Eau Claire County Treatment Courts – Treatment Court Referral Form
All fields with an asterisk (*) must be completed.
Referral Date (MM/DD/YYYY)*:
/
/
Referral Submitted By*:
Title/Organization*:
Phone No.*:
Applicant Last Name*:
Sex*:
Male
E-mail Address:
First Name*:
Female
Middle Name:
WI State ID No.:
Date of Birth (MM/DD/YYYY)*:
/
/
Age of Applicant:
Current Street Address*:
Current Phone No.*:
City*:
State*:
If in Jail, Street Address Prior to Incarceration*:
City*:
What county does the applicant live in?*
Eau Claire
Does the applicant have minor children?*
Yes
Chippewa
No
Dunn
COMPAS status*:
Requested
Yes
No
Completed
Does the applicant have pending charges?*
Other
If Yes, list age(s):
Has applicant ever served in the armed services (including basic training or boot camp)?*
Is the DA’s office aware of this referral?*
State*:
Unknown
Yes
If Yes, supportive?*
No
Yes
No
Unknown
Unknown
Yes
No
If Yes, list the County(ies), State(s),
Case No(s) and pending charge(s).
Does the applicant have any out-of-state convictions?* If Yes, list state and year:
Is the applicant currently on:
Probation?*
Yes
No Extended Supervision?*
Yes
No
If Yes, list the County(ies), State(s),
Case No(s), charge(s) and discharge date (from supervision).
Is this referral an Alternative to Revocation (ATR)?*
Yes
No
Hearing Date (if applicable):
If referral is an ATR, estimated length of incarceration if revoked:
Applicant’s DOC Agent*:
Phone No.:
Does the applicant currently have a felony DAGP?*
Yes
E-mail Address:
No
Any existing warrants?*
Does the applicant have past convictions for possession with intent to deliver?
Is the applicant a registered sex offender?*
Yes
Yes
Yes
No
No
No
Has the applicant been diagnosed with a mental illness?*
Yes
No
If Yes, what is the disorder?
Previous mental health treatment?
Yes
No (If known, list treatment type/facility/dates)
Previous AODA treatment?
Yes
No (If known, list treatment type/facility/dates)
Has the applicant previously been admitted into a treatment court?
Yes (Year?
Please submit form to: Ground Floor Reception, Dept. of Human Services
715-839-6500 [email protected]
Questions? Contact:
Melissa Ives, Treatment Courts Program Supervisor
715-839-7081 [email protected]
REVISED – 5/12/16
Where?
)
No