How
to Make a SPRITE Referral
To
Complete the Forms by Computer, follow the directions below.
Please print this page to use as a
referral checklist. Then print each form or save to your computer.
HOW TO MAKE A
DIRECT COUNTY REFERRAL TO THE 24-DAY
SPRITE PROGRAM,
OREGON, WI
1.
Make an
initial phone call to verify the student fits the selection criteria and
that there are openings. The SPRITE main office number is (608) 288-3356.
2.
Send via
mail, fax or email:
o
SPRITE
Referral and Face Sheet (DOC-1615)
o
County
worker’s email address and fax number; After-hours phone
o
Current court report and social history
To: SPRITE Program,
Attn: Jo Mercurio, Supervisor, 2909 Landmark Place, Suite 104
Madison, WI 53713 Phone: 608.288.3356 Cell: 608.235.6387 Fax:
608.288.3378 email: joann.mercurio@wi.gov
3. Obtain and
send appropriate authorizations, health information and signatures
o
Emergency medical care authorization for a minor (DOC-2196) signed by
parents/guardian. (Include name of insurance carrier and group/patient
number or MA number if applicable)
o
Physician Recommendation (DOC-2272 rev. 1/2010)
o
Psychiatrist Recommendation if youth is on psychotropic medication or has
been under a psychiatrist’s care. See list of inclusive medications on
the
Psychiatrist
Recommendation (DOC-2273 rev. 1/2008)
o
Authorization for Use and Disclosure of Protected Health Information
(DOC-1163A rev. 12/2007) allowing SPRITE to receive information from
physicians or urgent care facilities.
4. Get
student court-ordered to SPRITE. Judges may use WI Stat. 938.34 (7g) or
make SPRITE participation a condition of dispositional order.
5.
Schedule youth’s
interview date. All youth are required to have an interview either in
person (if possible) or by the telephone.
To allow for SPRITE
preparation please try to transmit all remaining material to SPRITE
fourteen (14) days prior to the start of the session.
6. If not
completed during youth’s interview, send the completed
Student
Questionnaire (DOC-1706) and
Rules and Expectations (DOC-1760)
7.
Interagency
Agreement (DOC-2245)
8.
Copy of the Court
Order requiring participation in SPRITE.
The County is
responsible for transportation of the student to and from the SPRITE
Program. County students must arrive at the SPRITE House between 11:00
a.m. and 12:00 noon on the first day of the session.
Graduation is at 10
a.m. on the final day of the session. Thank you.
Please print the
2009 SPRITE
schedule and map to
SPRITE.
