Eau Claire County Treatment Courts
 

All referrals to an Eau Claire County Treatment Court must be made through submission of a Treatment Court Referral Form. All fields with an asterisk (*) must be completed in order for the submission to be accepted. Note that other incomplete fields may delay a final determination regarding the referral. If all fields are complete, the Treatment Court Triage Team generally will determine the final disposition of a referral (i.e., whether the referred person will be accepted into a treatment court and, if so, which court) within 3-4 weeks of submission.

The WI State ID No. is the number assigned by the State Identification Bureau upon receipt of a criminal fingerprint card. If a COMPAS assessment already has been completed, the WI State ID No. may be found on the results of the assessment (if a COMPAS assessment has not been completed, please do not request one).

Questions?

Contact   Brenda Goettl, Treatment Court Supervisor
                715.839.6982, brenda.goettl@co.eau-claire.wi.us


All fields with an * must be completed
Referral Submitted By

Name: *
Title/Organization: *

Phone: * Email:




Applicant


Applicant Last Name: *
First Name: *
Middle Name:
Sex: * Male Female

Date of Birth: *   Phone: *

Current Street Address: *
City: *
State: *

If in Jail, Street Address Prior to Incarceration:
City:
State:

What county does the applicant live in? * Eau Claire Chippewa Dunn Other

WI State ID No:

Does the applicant have minor children? * Yes No
  If Yes, list the age(s) of the children




Is the DA's office aware of this referral? * Yes No Unknown
If Yes, supportive? Yes No Unknown

COMPAS Status: * Requested Completed Unknown

Has the applicant ever served in the armed services (including basic training or boot camp)? * Yes No




Does the applicant have pending charges? * Yes No
  If Yes, list the County(ies), State(s), Case No(s), and pending charge(s):
  

Does the applicant have any out-of-state convictions?* If Yes, list state and year:

Is the applicant currently on:  Probation? * Yes No   Extended Supervision? * Yes No
  If Yes, list the County(ies), State(s), Case No(s), charge(s) and discharge date (from supervision):
  

Is this referral an Alternative to Revocation (ATR)? * Yes No    
Hearing Date (if applicable):

If referral is an ATR, estimated length of incarceration if revoked:



Applicant's DOC Agent:*

Agent Phone: Agent Email:




Does the applicant currently have a felony DAGP? * Yes No

Any existing warrants? * Yes No

Does the applicant have past convictions for possession with intent to deliver? Yes No

Is the applicant a registered sex offender? * Yes No




Has the applicant been diagnosed with a mental illness? *
(e.g., schizophrenia, bipolar mood disorder, psychotic disorder, or major affective disorder)
Yes No
  If known, what is the disorder?

  




  Has the applicant received prior AODA treatment? Yes No
  (If known, list treatment type/facility/dates)
  

  Has the applicant received prior mental health treatment? Yes No
  (If known, list treatment type/facility/dates)
  


 Has the applicant previously been admitted into a treatment court? Yes No
 If Yes, Year? Where?


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