All clients admitted to a Milwaukee Crisis Stabilization House will be expected to sign the Admission Agreement below

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All CSH facilities are designated drug free “safe” zones. Personal possession of any medications (prescribed or otherwise), controlled substances, CBD unless

approved by CSH Medical Director, alcohol, chemical substances (such as aerosol sprays and paints/thinners), and over the counter pharmaceutical products without

an MD order) is prohibited. Staff will assist in maintaining a safe zone environment by conducting random searches which may include property, living quarters and

general areas, urine drug screens, breathalysers and other methods appropriate to the presenting situation. All medications and chemical substances must be

turned in to staff immediately upon entering the CSH.

I acknowledge that I have used/abused the following substances:

Client Initial

Client Initial

Client Initial















Prescription Meds




I agree to random drug screens, breathalyzer or urine drug screen


I agree to random checks of my belongings upon reentry to Crisis Stabilization House.


I agree to obtain medications only through my identified provider(s). All medical treatment accessed need verification. Clients must turn in any and all prescribed medications or prescriptions obtained documentation that indicates the complaints reported diagnosis/identified treatment needs and follow up instructions.


Avoid people who use. Avoid places where drugs are present.


I choose to redirect myself by doing the following




Attend support groups (circle) 1 2 3 4 5 6 7 times per week. (AA, NA, etc.)


See professional therapist or counselor for individual or group treatment.



I, the Client, acknowledge my awareness, understanding and agreement that any substance abuse or refusal to follow with established AODA programming will

result in my possible discharge. Resource information for comprehensive AODA services (such as the Milwaukee Detox Center and Access Points) will be provided to

me upon discharge, along with community resources including shelters and meal sites. We (the CSH) agree that we will make arrangements to discharge you, the

Client, to a safe place within he community.

Client Signature:                                   Date:                     



Clinician/Witness Signature:                         Date: