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SEX OFFENDER PROGRAM REPORT - MALES
OFFENDER NAME (Last, First, MI)
DOC #
SID#
DOB
REPORT TYPE
|_| INITIAL |_| PROGRESS |_| DISCHARGE / EXIT
| REPORT DATE |
| MR/PMR/ES DATE |
DISCHARGE DATE
AGENT #
FACILITY/ AGENCY
PROGRAM NAME / PHASE
PROGRAM TYPE
FACILITATOR(S) NAME(S)
ENTRY DATE
EXIT DATE
PROGRAM HOURS COMPLETED
PART I: RISK LEVEL - FROM DOC-3776 SEX OFFENDER TREATMENT EVALUATION - MALES
TOTAL STATIC 99-R SCORE:
CATEGORY: |_| I Very Low (-3,-2) |_| II Below Average (-1,0) |_| III Average (1 – 3) |_| IVa Above Average (4 , 5) |_| IVb Well Above Average (6+)
PART II: STATUS OF TREATMENT NEED(S): STABLE – 2007 (Required)
| Problems |
| Unable to Score |
| None (0) |
| Some |
(1)
| Definite (2) |
| Rationale / Comments |
| Significant Social Influences |
| |_| |
| |_| |
| |_| |
| |_| |
| Capacity for Relationship Stability |
| |_| |
| |_| |
| |_| |
| |_| |
| Emotional Identification with Children |
| |_| |
| |_| |
| |_| |
| |_| |
| Hostility Toward Women |
| |_| |
| |_| |
| |_| |
| |_| |
| General Social Rejection / Loneliness |
| |_| |
| |_| |
| |_| |
| |_| |
| Lack of Concern for Others |
| |_| |
| |_| |
| |_| |
| |_| |
| Impulsive Acts |
| |_| |
| |_| |
| |_| |
| |_| |
| Poor Cognitive Problem Solving |
| |_| |
| |_| |
| |_| |
| |_| |
| Negative Emotionality / Hostility |
| |_| |
| |_| |
| |_| |
| |_| |
| Sexual Preoccupation / Sex Drive |
| |_| |
| |_| |
| |_| |
| |_| |
| Use of Sexual Activity for Coping |
| |_| |
| |_| |
| |_| |
| |_| |
| Deviant Sexual Interests |
| |_| |
| |_| |
| |_| |
| |_| |
| Cooperation with Supervision |
| |_| |
| |_| |
| |_| |
| |_| |
| TOTAL STABLE SCORE: |
| CATEGORY: |
| |_| LOW (0-3) |
| |_| MODERATE (4-11) |
| |_| HIGH (12 OR MORE) |
| COMBINED STATIC/STABLE CATEGORY |
| |_| I Very Low |
| |_| II Below Aver. |
| |_| III Average |
| |_| IVa Above Aver. |
| |_| IVb Well Above Aver. |
Rationale for Ratings / Offender Interview Notes:
DEPARTMENT OF CORRECTIONS WISCONSIN
Division of Adult Institutions Division of Community Corrections DOC-3777 (Rev. 7/2018)
DISTRIBUTION: Original (DAI) – PSU Record, SOT/Ch. 980 Section; Official Record - DCC Offender Case File, Mental Health Section Original (DCC) – DCC Offender Case File, Mental Health Section
PART III: PROTECTIVE FACTORS: SAPROF - check all that apply (Required)
The presence of any of the factors listed below may support or assist desistance from sexual offending.
| X = UNABLE TO SCORE |
| 0 = NOT PRESENT |
| 1 = PRESENT TO SOME EXTENT |
| 2 = CLEARLY PRESENT |
| INTERNAL FACTORS |
| X |
| 0 |
| 1 |
| 2 |
| RATIONALE / COMMENTS |
| Key |
| Goal |
| 1. Intelligence |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 2. Secure Attachment in Childhood |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 3. Empathy |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 4. Coping |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 5. Self - Control |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| MOTIVATIONAL FACTORS |
| X |
| 0 |
| 1 |
| 2 |
| RATIONALE / COMMENTS |
| Key |
| Goal |
| 6. Work |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 7. Leisure Activities |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 8. Financial Management |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 9. Motivation for Treatment |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 10. Attitudes toward authority |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 11. Life Goals |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 12. Medication |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| EXTERNAL FACTORS |
| X |
| 0 |
| 1 |
| 2 |
| RATIONALE / COMMENTS |
| Key |
| Goal |
| 13. Social network |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 14. Intimate relationship |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 15. Professional care |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 16. Living circumstances |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 17. External control |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
TOTAL: / 34
RATIONALE FOR SAPROF RATINGS:
FINAL JUDGMENT ABOUT STRENGTH OF SAPROF PROTECTIVE FACTORS
| |_| LOW |
| |_| LOW-MODERATE |
| |_| MODERATE |
| |_| MODERATE HIGH |
| |_| HIGH |
PART IV: RESPONSIVITY FACTORS
| |_| Reading comprehension may be below 6th grade level |
| |_| Language Barrier |
| |_| IQ may be below 80 |
| |_| Hearing Impaired |
| |_| Unstable Psychological Status (refer) |
| |_| Evidence of serious social skills impairment due to developmental or psychological concerns |
Other ADA condition that may affect treatment responsivity (describe):
Other / Details:
PART V: PROGRESS OR DISCHARGE SUMMARY (Narrative)
PART VI: PROGRAM STATUS / WICS DISCHARGE STATUS / RECOMMENDATION
(this section required only upon completion, withdrawal or termination)
| |_| Enrolled / Continuing |
| |_| Terminated – No Fault |
| |_| Aftercare - Community |
| |_| Withdrew |
| |_| Completed |
| |_| Terminated - Staff |
| |_| Aftercare - Institution |
When the discharge status is “Terminated – No Fault” indicating placement is inappropriate, indicate the recommended placement and place on the WAIT LIST status for:
|_| Reoffense prevention plan (DOC-2456 or DOC-2456A) completed by offender and sent to supervising agent (Discharge/ Exit Report only).
PART VII: RECOMMENDATION(S)
CLINICIAN NAME (type or print clearly)
| CLINICIAN SIGNATURE |
| DATE SIGNED |
SUPERVISOR NAME (as needed)
| SUPERVISOR SIGNATURE |
| DATE SIGNED |