Admissions & Referrals

Your Info

Name

Phone

Client Info

Name

Sex Assigned at Birth Male Female

Gender Identity

If other, describe

Address

City

State

Zip

Funding Source

Other Funding

Desired Placement

If other, describe

Preferred Location

Legal Status

Diagnoses Brief Description of Reason for Referral

Individual Needs

On the sex offender registry

Fully ambulatory (not in need of any assistive devices or assistance)

At least 18-years-old

Capable of completing all personal cares without assistance

Medically stable with no need for ongoing professional nursing care

Current/history of substance abuse

Current/history of aggression towards staff, peers, or property

Current/history of elopement

Current/history of suicidal ideations or attempts

Able to be placed in a bedroom with a roommate

On probation

In agreement with placement

Capable and willing to follow program rules and staff directives

Comments

People Involved

Provide information for any involved (e.g. social worker, case worker, protective placement, MCO, PO, etc.)

Name

Phone

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Corporate
Headquarters

2411 N Hillcrest Pkwy, Ste 6
Altoona, WI 54720

715-831-3910
Fax: 715-831-3911

Southern Lakes
Regional Office

848 S Janesville St
Whitewater, WI 53190

262-473-8144
Fax: 262-473-0622

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Northeast
Regional Office

619 N Lynndale Dr
Appleton, WI 54914

920-738-5393
Fax: 920-738-5394

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