Fill and Sign the 512018 Wisconsin Legislature Form

ME-912, 12/02 Treatment Conditions §51.20(13)(dm), W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF THE CONDITION OF Name of Subject Treatment Conditions Date of Birth Case No. For Official Use The court has ordered the following outpatient treatment conditions pending the final hearing: or, The appropriate department imposes the following outpatient treatment plan and condition: Check all that apply. Keep appointments with court-appointed examiners. Take all doses of psychotropic medication prescribed for me. Keep all appointments with treatment providers and case management staff. Cooperate with psychological and/or psychiatric testing and therapy. Keep case management or treatment staff advised of current residential address or location. Refrain from any acts, attempts, or threats to harm myself or others. Refrain from ingesting any controlled substances not prescribed for me. Refrain from consuming alcoholic beverages. Other conditions: I understand that if I violate any of these conditions, I may be taken into custody by law enforcement and transferred to an inpatient facility. I agree to comply with these conditions. Subject’s Signature Distribution: 1. Court – Original 2. Subject 3. Counsel 4. Treatment Provider 5. Outpatient Treatment Facility Date Copy given to subject on: By: Print Name