ORDER FOR ASSESSMENT AND DRIVER SAFETY PLAN REPORT ‘Wisconeia Department of Transportation ‘948.488, 249.20, tq), oF 343:305(10) Wis. Stats Mvaes4 ‘rz008 DL amonded Nam Last, Fest, Wi) BAD Sax” [Diver Lcwnwe Nanbor ae HOFFWANN,TAMAMTY.L 2617-1068 Pe | Rgs-er26087-00 hi Tass Giy,Suia, TP Cove Touity of Resdence | Rea Gade Telephone ‘810 NBROADWWAY GREEN BAY, vi 54203 BROWN Taae Go Adare SRR Cay, AP CONS) Giant Seupaton aa RE Saar Gata aa TaRUTS aor aera Caron DAO) BHTOSE2T ‘Arrest information ‘Arrest Dates) Higeatea Fo zr 2022001 ED Controted Substance and/or Other impairing Drug: Blood Alcon Laver 1 implied Consent ‘OWI- Operating While Intoxicated “{L] Repeat Offense or EW — Injur OW! ~ Great Bodily Harm. Tl owl Homicide oral fetive OWW Area 3 Referral information: Court Ty bor Voluntary “savant Fndnge: Paste GSS25 Gt COPS RTC] Wn iaH a caved sober o Ober rags Check Waker. Comet form HOSES, (C1 stresponsible Use of Alcohol (1U) Cl irresponsible Controlled Substance andor Other Drug Use (\U) Li responsible Use ot AcobolBorderine (118) __[] irtesponsibie Use of Contoled Substance andlor Other Drug Use ~ Borerine (UB) (D1 Suspected Aicahot Dependency 10) Suspected Controlled Substance Dependency and/or Other Drug {B3 Aicono! Dependency [C1 Controlled Substance and/or Other Drug Use Dependency (1 Atcaho! Dependency n Remission 5 Coniraes Sutetanoe andlor Other Ohug Use Dependency in Remission Please check airkeng pation and hronlaly fF Szabo) Zepondancy or suspected alcohol dependency fangs. Drinking Pattern ‘Drug Usage Pattam Co inerritrt 2] Rocuent 1 steagy [PT iemter CC] Recurent 1 sway ‘Alcohol Chroatay Tasaatey T Big Chronietyy odes Chewy Cl Advanced C1 Forravances | C) eas (1 Aavances 1 Faratvances Taarily Bhyaiclogical, Behavioral, Payehological andlor Atituinal Sympioms eee yea ga. Relef Use, 022 - Preference for Compantonsi.ceatons, 028 - Legal Problems, 091 - Prot Tx, 038 - Change in Tolerance, (982 - Family ienspions (2) ‘aseeamrent natanOR Vows ‘MVa849 Wisconsin Assessment of the Impairad Driver (WAID) 1 other- Piesse identity: Records arson Carisleling Ascessment TileiCeniicalion Brenda Franco CSAC IDP-AT ‘acosament Facity Name ] Tarephone Nuribor Racin Adaress ‘Brown County Hurtan Services [920291 698 ‘3160 Garshwin Or. Green Bay $4311 ‘Giver Safely an Proce? BELLIN PSYCHIATRIC CENTER 425620189, Raisone bate Ralease Bipaton Gate Soaniy Riorzad wo Recave Released Warvaion- Give Name 09-28-2022 326-2023 Brown "AUTHORIZATION FOR RELEASE OF INFORMATION | tne undersigned lent, consent to the reloase of the rasuls of We assessment and the driver safety plan complotes bythe person named above. roan rer eet c tecerde, beatment cords, stendance records and other Information required. This information my be released prior to the Hees fateh deo, and to the drvar safety plan provider of my choice. named above, ond tothe appropriate deparinent in the above names ‘County Under 9.61.42 Wis, Stata. or fis approved agency the Wisconsin Department of Transporation “Toa purpose for bis disclosures to ai n determining complance wth the court or Wieconsin Dapartment of Transporation order and competency Fenner conte: furher sutnorze tha prsorvfaciy completing the aseesement fol up and verfy my complance wit the driver ea clr ecloretne tat may withdraw my conzent at any te, plato te expraion of tis elegce, Racleosura of al rfemation i rofibed under § 8.2. 32(0), 42 Code of Federal Regulations, Pat I 0928-2002 wae Simin Sgrahae Wola ania 8 (Crp Toa) Distribution: 1 — Assessment; 2~ Plan Provider; 3~DOT: 4~Glient® DRIVER SAFETY PLAN ORDER ‘Wissonsln Department of Tranaportation west pa D Amended ara Tea TT arpa Jes aamonane Sree Le ‘aoa ana 5 TROT PEN PO Ray STAT rsoateesoer " mourns “This Besasament condarre above dent's use of the following - Check ali that apply | Recommended Wisconain Traffic Safety Program at [& Alcohoi Cl Other Drugs: (Cl Controlied Substances Group Dynamics [1] Multiple Offender Program S| Rag a OTRO we Subatent | SB rans ee gaa aa Cl ecmen [oes Mar Evaluation _ Victim impact Pane! Cl Medical Exam ) Payehiatric “Explain need and describe egimen and curation Mast abstain fron all AOD's. No CRD products. Random UA screens, provider: Ti Detorincator Ci) Resident” —_C) Day Treatmene C] other” Treatment TBD by Provisar Name BELLIN PSYCHIATRIC CENTER #2589018 Broader Area Gade Telephone Nanwar 19204335650 Praikie Rdsiess, Cay, Sete ZF Code 201 E ST JOSEPH ST GREEN BAY Wi $4305 “The Wisconsin Department of Transportation will be notited if th citent falls to substantially comply withthe driver safety plan Copies of this rapar wil be lsitbuted to the Wisconsin Department of Transporation, the county department, uncer 8.64.42 ‘orits approved agency, the diver safety plan provider named above, and the cliant. State, | understand the recommendatlons made above, that my participation in the plan will make me more aware of tie affects of driving while Intoxicated on vietins and their familie, and agree to comply. | further understand that it its discovered that | provided the assessor, uth any Iwalld information this aseessment can be Considered vord. | have been informed as to the fee provisions under 6.48.03(18)f) Wis. Slate. for assesement and criver safely plan costs, | agree to sat an appointment with my chosen diver safety plan provider, wes Shabove, within 72 hours. |further understand that if! fal to comply with the driver safety plan, the Wisconsin Department ot fon wil withdraw my drivers fcense indefinitely until | complote the plan satisfactory 09-28-2022 eae Raleaza of afermcion Bape 08-28-2023 LICENSING RECOMMENDATION NOTE: Persons whose dependence on alcohol, drugs, or controlled substances has attained such a degree that it substantially inierferes wth physical or mental Health, of socal or economic functioning, should not drive @ vehicle, On the basis of your knowledge ‘of this client, indicate which of the following choices you recommend. 1 License Issuance Plan Compliance {Education and/or Treatment) as a Condition to Licensing License Denial - Reason - Attach further documentation, If necessary. Brown County Haman Servioes Brenda Franc cara Fay Nae) Taser Was) ‘oSAC IDF At oo-2e2002 Tero) CT TROT Daiay Distribution: ‘- Assessment; 2 Plan Provider; 3~ DOT; 4— ClientIGNITION INTERILOCK DEVICE (11D): INSTALLATION/AEMOVAL RECORD vases, 1OECID. Tang S13 Wa Aan, Cole nctallation Prodedurs-Seriog Provide’ ‘Checkbox er INSTALLATION and indicate date ‘Give Paga | to cusiomer as feospt of iatelaton, Adal Page 2 County Sheri Heo seen net coe A DINSTALLED Dawe” -Y:200e nomen Ospavoret f Tension Ger etwnatn Sone PO eee adion i 970.16 Removal Procedure -Sorvies Provider ‘Cheticbonx for REMOVAL and indented. ‘tn 3 working day afer removab ot costo: Electenivally noty DMV otveroval and smal Page 449. County Shari Cl woaewoven on ceri I Dever Iastatinnancalratin wl rename th Opin ob et (OM. eee Se Ciseor aya es sage 38 eu neers ee ae aes aon your tonnes breton 7 |Jdo€ Fhe. ThOny. Je EMC UOGD [HUES 73 ‘omnee information = oittrent irom Driver ors hlQ.—/.- Bodo. _[ISss2eetanaa GOL BA) aa SRD Bhan io nip Hi i BeeTAMMY HOFFMANN 810 N BROADWAY GREEN BAY Wi 54303, 920-362-6628 (home) Page: 1 of 4 Printed: 9/21/2022 8:44 AM CDT Date Range: 9/21/22 « PATIENT I Gender. female DOB: 12/17/1965 ‘9721722 Wed 8:00 AMDT Belin Health Psychiatric Center - Green Bay for ADA Intal Vist with lum, Ansley E, MA LPC ‘csAc Diteations: We are located at 301 East St Joseph Stn Green Bay. Our phone number is 820-433-6073, eB TT SGOPICOY Belin Healin Paychiatie Genter Green Bay tor AODA Folow up Wal wih Blum, Alley E, A Lee csac TOE Tae TGOPU COT Balin Health Paychatie Cantar - Green Bay Tor AODA FOroW up Vistwith Bhim, Ansley E, MA Lec esac TOHTBE Tus S30 PM ODT Belin Health Paychiatic Carter Green Bay for AODA Faliow up isk wih Blum, Arley E, MA Lec osac TORTEE Won SO PAT EBT atin Health Paychiatie Garter - Green Bay for SODA Fala up nial Bias Anatoy ETA i eat Leo osac (ora6i22 Tue 330 PM COT “Balin Health Paychiatic Cantar - Green Bay Tor AODA Follow up Visi with Buin, Alay E. MA Lec esac Tne Te SSOPM CY Balin Heath Paychiatic Gorter Green Bay for AODA Polow up Vis wih Bhim, Ainsley E, MA LPC CSAC.