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SEX OFFENDER PROGRAM REPORT - FEMALES
OFFENDER NAME (Last, First, MI)
DOC #
SID#
DOB
RPORT 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 / NEED ASSESSMENT - FROM DOC-3776A SEX OFFENDER TREATMENT EVALUATION - FEMALES
NOTE: Female sex offenders are generally low risk to sexually re-offend. Overt statements by the offender about intention to re-offend may indicate that a higher risk level is appropriate.
| OFFENDER HAS MADE STATEMENTS REGARDING INTENTION TO SEXUALLY RE-OFFEND |
| |_| YES |
| |_| NO |
| PREVIOUS TREATMENT /NEED CATEGORY: |
| |_| Very Low |
| |_| Below Average |
| |_| Average |
| |_| Above Average |
| |_| Well above Average |
PART II: STATUS TREATMENT NEED(S) – (required)
| RATING GUIDE: |
| 0 = minimal or no need for improvement |
| 1 = some need for improvement |
| 2 = considerable need for improvement |
| 3= very considerable need for improvement |
| INTIMACY &RELATIONSHIP ISSUES |
| 0 |
| 1 |
| 2 |
| 3 |
| Rationale / Comments |
| 1. Intimacy Deficits |
| |_| |
| |_| |
| |_| |
| |_| |
| 2. Dysfunctional Relationships |
| |_| |
| |_| |
| |_| |
| |_| |
| COGNITIVE PROCESSES |
| 0 |
| 1 |
| 2 |
| 3 |
| Rationale / Comments |
| 3. Pro-Offending Attitudes / Cognitions |
| |_| |
| |_| |
| |_| |
| |_| |
| 4. Antisocial Attitudes |
| |_| |
| |_| |
| |_| |
| |_| |
| 5. Distortions of Self |
| |_| |
| |_| |
| |_| |
| |_| |
| EMOTIONAL PROCESSES |
| 0 |
| 1 |
| 2 |
| 3 |
| Rationale / Comments |
| 6. Use of Sex to Regulate Emotional States |
| |_| |
| |_| |
| |_| |
| |_| |
| 7. Emotional Dysregulation |
| |_| |
| |_| |
| |_| |
| |_| |
| 8. Revenge / Humiliation as Instrumental Goal |
| |_| |
| |_| |
| |_| |
| |_| |
| 9. Substance Use / Misuse |
| |_| |
| |_| |
| |_| |
| |_| |
| SEXUAL DYNAMICS |
| 0 |
| 1 |
| 2 |
| 3 |
| Rationale / Comments |
| 10. Sexual Gratification |
| |_| |
| |_| |
| |_| |
| |_| |
| 11. Sexual Abuse / Victimization |
| |_| |
| |_| |
| |_| |
| |_| |
| 12. Sexuality and Sexual Beliefs |
| |_| |
| |_| |
| |_| |
| |_| |
| 13. Deviant Sexual Interests |
| |_| |
| |_| |
| |_| |
| |_| |
| SOCIAL FUNCTIONING |
| 0 |
| 1 |
| 2 |
| 3 |
| Rationale / Comments |
| 14. Antisocial Associates |
| |_| |
| |_| |
| |_| |
| |_| |
| 15. Education |
| |_| |
| |_| |
| |_| |
| |_| |
| 16. Employment |
| |_| |
| |_| |
| |_| |
| |_| |
| 17. Parenting |
| |_| |
| |_| |
| |_| |
| |_| |
| CURRENT TREATMENT NEED RATING: |
| |_| Very Low |
| |_| Below Average |
| |_| Average |
| |_| Above Average |
| |_| Well above Average |
RATIONALE FOR NEEDS RATING:
DEPARTMENT OF CORRECTIONS WISCONSIN
Division of Adult Institutions Division of Community Corrections DOC-3777A (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 useful in treatment planning.
| 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 |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
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):
PART V: INITIAL PROGRESS OR DISCHARGE SUMMARY (Narrative)
PART VI: PROGRAM STATUS / WICS DISCHARGE STATUS
(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” because 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