Free Conditional Release Rules and Conditions - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-25614 (04/2009)

STATE OF WISCONSIN

Administrative Code DHS 98

CONDITIONAL RELEASE RULES AND CONDITIONS
Signing this form is voluntary. Refusal to sign this form may lead to revocation of conditional release.

Name ­ Client (Last, First MI)

ID Number

,
As established by Administrative Rule DHS 98, you have an opportunity for administrative review of certain types of decision(s) through the client complaint process. The following rules are in addition to any court-ordered conditions. Your conditional release may be revoked if you do not comply with any of your court ordered conditions or if you violate any of the following rules: 1. You shall avoid all conduct which is in violation of federal or state statute, municipal or county ordinances or which is not in the best interest of public welfare or your rehabilitation. 2. 3. 4. You shall report all arrests or police contact to your agent within 72 hours. You shall cooperate fully with all court ordered conditions of release. You shall make every effort to accept the opportunities and counseling offered by supervision. The confidentiality of drug and alcohol treatment records is protected by federal laws and regulations. Generally, treatment program personnel may not reveal to an individual outside the Department of Health Services or the Department of Corrections that a client is attending the program or disclose any information identifying him/her as a drug/alcohol abuser unless: a. You consent in writing. b. The disclosure is allowed by a court order. c. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit or program evaluation. d. You commit or threaten to commit a crime either at the program or against any person who works for the program. A release of information is not required for communication between DHS and DOC. Violation of the Federal law and regulations by a program is a crime. These regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate authorities. Refusal to sign the consent for releasing information, including placement for treatment, shall be considered a refusal of the program. 5. 6. 7. 8. 9. You shall cooperate fully with all treatment recommended by your mental health providers and agent. You shall abide by all rules of any detention or mental health facility in which you may be confined and or treated. You shall report to your agent as directed for scheduled and unscheduled appointments. You shall submit a written report monthly as directed by your agent. You shall provide true and correct information orally and in writing in response to inquiries by the agent.

10. You shall make yourself available for searches or tests ordered by your agent including but not limited to urinalysis, breathalyzer and blood samples or search of residence or any property under your control. 11. You shall inform your agent of your whereabouts and activities as he/she directs. 12. You shall not change residence or employment unless you get approval in advance from your agent or in the case of an emergency, notify your agent of the change within 72 hours. 13. You shall not leave the country. You shall also not leave the State of Wisconsin, Administrative rule DHS 98.04(3)(k) prohibits all out of State travel. 14. You shall not purchase, trade, sell or operate a motor vehicle unless you get approval in advance from your agent and case manager. 15. You shall not purchase, possess, own or carry any firearm pursuant to Wis. Stats. s 941.29 and federal law 18 USC § 922 (g)(4). Your agent may not grant permission to carry a firearm. You shall not purchase, possess, own or carry other weapons, as defined by your agent, unless you secure advance approval from your agent. 16. You shall not purchase, possess or consume any alcohol or other drugs not prescribed by your treating physician. 17. You shall not borrow money or purchase on credit unless you get approval in advance from your agent. 18. You shall follow all specific rules that may be issued by an agent to achieve the goals and objectives of your supervision. The rules may be modified at any time as appropriate. The specific rules imposed at this time are stated on the back of this form. You shall place your initials at the end of each specific rule to show you have read the rule.

I reviewed and explained these rules to the client. SIGNATURE - Agent Area Number

I received a copy of these rules. SIGNATURE - Client

Date Signed