Fill and Sign the Outpatient Treatment Conditions Wisconsin Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF THE CONDITION OF       Name of Subject Treatment Conditions       Date of Birth Case No.       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. Distribution: 1. Court – Original 2. Subject 3. Counsel 4. Treatment Provider 5. Outpatient Treatment Facility Subject’s Signature       Date Copy given to subject on:       By:       Print Name ME-912 , 12/02 Treatment Conditions §51.20(13)(dm), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material.