Attachment 5 DOC-1336 Referral to Purchase Offender Services.pdf

WISCONSIN

DISTRIBUTION: Original – DCC Offender Case File

DEPARTMENT OF CORRECTIONS

Division of Community Corrections DOC-1336 (Rev. 3/2017)

REFERRAL TO PURCHASE OFFENDER SERVICES

• A signed DOC-1163A MUST be completed by the offender, who is the subject of this referral, prior to the release of any Protected Health Information (PHI) to any external contracted treatment provider.

• COMPAS Bar Chart and Narrative must be included with this referral

OFFENDER NAME (Last, First, M.I.)

DOC#

SID#

DOB

SEX

M F

Transgender/intersex

OFFENDER CURRENT ADDRESS

TELEPHONE (include area code)

OFFENDER EMAIL ADDRESS

LIMITED ENGLISH PROFICIENCY

Yes No, if Yes, what language:

DATE OF ORDER TO

DETAIN (DOC-212)

REFERRAL DATE

PROJECTED

ELIGIBILITY DATE

DISCHARGE DATE

REFERRING AGENT NAME

AGENT #

CFS NAME

CFS EMAIL ADDRESS

AGENT TELEPHONE NUMBER

AGENT EMAIL ADDRESS

REFERRAL PROGRAM NAME

REFERRAL PROGRAM LOCATION

REASON FOR REFERRAL

(check all that apply) Alternative to Revocation (ATR) EBRV Recommended (NOT AN ATR) Identified Need

(Describe / explain problems, behaviors evidenced by offender and specific programs services that are being requested):

COMPAS RISK LEVEL RECOMMENDATION LOW MEDIUM HIGH

IF LOW –

(check all that apply)

Operating While Intoxicated 2nd or 3rd Court ordered Domestic Violence Treatment

Sex Offense convictions requiring policy override. Supervision overrides due to new significant violations / offenses where referral to programming or ATR is appropriate.

COMPAS TRAILER TOOLS:

Static 99

URICA

Other

RESPONSIVITY / BARRIERS (check all that apply)

YES NO YES NO

Health problems Lack of transportation

Need assistance due to learning disabilities Employment hours conflict

Need assistance due to physical disabilities Residential Instability

Need assistance with reading and/or writing Other (specify):

Is Offender taking medication Yes No, If yes, indicate medication name, type and reason for prescription, as well as whether medication is self-pay or covered by insurance.

History of mental health problems? Yes No If yes, is mental health well-managed / stable? Explain how mental health is currently managed:

Has Offender participated in previous outpatient or inpatient treatment services? Yes No

If Yes, list all previously attempted, attended service programs (i.e. AODA, DV, SOT, CBP, HWH etc.)

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RFB CJO-7468

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