6800 APPENDIX 13 SO PrgrmReprtAdaptiveMale (DOC-3777B).docx
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- Contract number
- 410036-M19-CJO6800-RFB-00
- Issued by
- Wisconsin
About this file
This document is a standardized assessment form (DOC-3777B) used by the Wisconsin Department of Corrections, specifically its Division of Adult Institutions and Division of Community Corrections, for evaluating male sex offenders participating in adaptive treatment programs. The form serves as a comprehensive reporting tool for initial assessments, progress evaluations, and discharge summaries for offenders with developmental and intellectual limitations who have committed sexual offenses.
The document outlines an assessment framework utilizing the ARMIDILO-S (Assessment of Risk and Manageability for Individuals with Developmental and Intellectual Limitations Who Offend Sexually) scoring system to evaluate risk factors, protective factors, and responsivity considerations. The form captures critical data including Static 99-R risk scores categorized from Very Low to Well Above Average, stable and acute client factors across eleven domains (supervision compliance, treatment compliance, sexual deviance, emotional coping, relationships, substance use, mental health, and others), and protective factors using the same framework. The assessment process supports program placement decisions, treatment planning, and discharge recommendations, with completed forms distributed to various correctional units including the PSU Record, Social Service Files, and Community Provider agencies for comprehensive case management and supervision continuity.
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Text version
SEX OFFENDER PROGRAM REPORT ADAPTIVE - 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-1577 SEX OFFENDER PROGRAM REPORT
TOTAL STATIC 99-R SCORE:
| CATERORY |
| |_| 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): ARMIDILO-S
Assessment of Risk and Manageability for Individuals with Developmental and Intellectual Limitations Who Offend Sexually. Use scoring definitions from ARMIDILO-S scoring manual
| RISK FACTOR RATING |
| -X = Insufficient information to score the item |
| -Y = Item is definitely present |
| -S = item is somewhat present |
| -N = Item is not present |
| -X |
| -Y |
| -S |
| -N |
| Critical Item |
| Stable Client Factors (rationale) |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 1. Supervision Compliance: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 2. Treatment Compliance: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 3. Sexual Deviance: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 4. Sexual Preoccupation / Sex Drive: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 5. Offense Management: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 6. Emotional Coping Ability: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 7. Relationships: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 8. Impulsivity: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 9. Substance Use: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 10. Mental Health: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 11. Unique Considerations: |
Acute Client Factors
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 1. Changes in Compliance with Supervision or Treatment: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 2. Changes in Sexual Preoccupation and Sex Drive: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 3. Changes in Victim-Related Behaviors: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 4. Changes in Emotional Coping Ability: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 5. Changes in Use of Coping Strategies: |
| RATING OF ARMIDILO-S RISK / NEEDS SCORE: |
| CATEGORY: |
| |_| LOW |
| |_| MODERATE |
| |_| HIGH |
DEPARTMENT OF CORRECTIONS WISCONSIN
Division of Adult Institutions Division of Community Corrections DOC-3777B (Rev. 7/2018)
DISTRIBUTION: Original (DAI) – PSU Record, SOT/Ch. 980 Section; Official Record (Discharge/Exit Report Only) – Social Service File, Confidential Envelope; Official Record - DCC Offender Case File, Mental Health Section Original (DCC) – DCC Offender Case File, Mental Health Section; Copy – Community Provider
DISCUSSION OF OVERALL RISK / NEEDS DETERMINATION:
PART III: PROTECTIVE FACTORS: ARMIDILO-S (Discuss protective factors)
PROTECTIVE
FACTOR RATING
| +X = Insufficient information to score the item |
| +Y = Item is definitely present |
| +S = Item is somewhat present |
| +N = Item is not present |
| +X |
| +N |
| +S |
| +Y |
| Critical Item |
| Stable Client Factors (rationale) |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 1. Supervision Compliance: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 2. Treatment Compliance: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 3. Sexual Deviance: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 4. Sexual Preoccupation / Sex Drive: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 5. Offense Management: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 6. Emotional Coping Ability: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 7. Relationships: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 8. Impulsivity: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 9. Substance Use: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 10. Mental Health: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 11. Unique Considerations: |
Acute Client Factors
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 1. Changes in Compliance with Supervision or Treatment: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 2. Changes in Sexual Preoccupation and Sex Drive: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 3. Changes in Victim-Related Behaviors: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 4. Changes in Emotional Coping Ability: |
| |_| |
| |_| |
| |_| |
| |_| |
| |_| |
| 5. Changes in Use of Coping Strategies: |
| RATING OF ARMIDILO-S RISK / NEEDS SCORE: |
| CATEGORY: |
| |_| LOW |
| |_| MODERATE |
| |_| HIGH |
RATIONALE / DETAILS FOR SCORINGS:
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 / Details:
PART V: INITIAL, PROGRESS OR DISCHARGE SUMMARY (Narrative for above items)
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 |
RECOMMENDATIONS:
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 supervising agent (Discharge/ Exit Report only).
CLINICIAN NAME (type or print clearly)
CLINICIAN SIGNATURE
DATE SIGNED
SUPERVISOR NAME (as needed)
SUPERVISOR SIGNATURE
DATE SIGNED
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