Case 2018CF000301 Document 22 Filed 09-10-2018 Page 1 of 1

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Alternative Sanction Programs
25 Keslsel Court
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h EAEftll weiIlness recovery^!
Madison, Wl 53711
Phone:(608)280-2652 1
Fax : (608) 280-26?jlEO
Sharing the Path from Hope to Recovery
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Dane County Alternative Sanction Programs Summary
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DANE COUNTY bfRCUIT COURT
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Client Name"^Wryv\..A. CXCizr\ \\\ DOB...\\ . Phone 4: O "* Q) )
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Address^ yv^frYy \<L{(TaCJL 4- Attorney CX\\ N(aV^ o\a^ ...

Gender: (0)/F Race: CjOatY- o6^&0 Probation: Y (^TXgent:__________ ;_____- • P

LSI-R:SV Score* SUD Indicated □ Not Indicated

Clinician signature/credentials
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* The Level of Service Inventory - Revised: Screening Ver^fLsi-R: SV) is an evidence-based, brief
screening tool used to determine the need for further evaluation of risk/needfactors for individuals
involved in the criminal justice system. The LSI-R: SV scoring is based on self-reported information
from the preceding 12-month period, including: prior convictions, age offirst arrest, employment­
-history, substance use history, mental health history, and attitudes towards crime.
' ■ " - ' 1 ■' '• ...............................■■■’i - .......................................................... 5 .................................................

n REFERRAL FOR CLINICAL ASSESSMENT

\
fDATE:
:
1 TIME: p

AM.... PM..1 ;
Clinician Notes/Comments: ; PLACE:
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CUU«, i
i Journey Mental Health Center j
25 Kessel Court
9-Co o '(2 ($%(j2 S Madison
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j WI 53711 i
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Please note: Failure to complete the clinical assessment will result in

□ ineligibility for participation in the Alternative Sanction Programs.

CONSULT WITH ATTORNEY FOR POSSIBLE REFERRAL TO DPU PROGRAM

□ EXPLAIN;
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Client Signature....
ii
-j Date ISE& *3
Distribution of Forms: Keep originalforfile. Give copy to client.

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