ATTACHMENT_1_-_14-R-0011_-_1.pdf

ATTACHMENT 1 CSOSA-14-R-0011

Revision Effective 10/20/11

CSOSA SEX OFFENDER REFERRAL AND FUNDING AUTHORIZATION FORM

Offender Name: PDID#

Address: Sex Offense:

Telephone #: Treatment

Phase:

PACKAGE DOCUMENTATION

Court/Release Certificate [REQUIRED] PSI PD163 Victim Impact Statement

Signed ROI Form [REQUIRED] Request for Treatment Extension Mental Health Evaluation(s)

Other Information:

SERVICES REQUESTED

Approved

Amount ITEM NO. SERVICE DESCRIPTION AND COST: FY 14 # of Total Units

Requested

# of Units

Funded

# of Units

Available

Individual Assessment Session (50 Minutes)

Individual Treatment/Aftercare/Booster Session

(50 Minutes)

Group Assessment Session (90 Minutes)

Group Treatment/Aftercare/Booster Session (90

Minutes)

Assessment: Offense Specific Polygraph and

Report

Offense Specific Polygraph and Report

Assessment: Sexual History Polygraph and Report

Sexual History Polygraph and Report

Assessment: Maintenance Polygraph and Report

Maintenance Polygraph and Report

Assessment Report

Plethysmograph and Report

TOTAL SERVICES AMOUNT APPROVED /CANCELLED

CSOSA INTERNAL REFERRAL REVIEW/FUNDING AUTHORIZATION FORM

Referring CSO Name: Date Referral Submitted to SCSO:

Approving SCSO Name:

SCSO Signature:

SCSO Decision and Date:

□ Approve □ Disapprove

COTR Name:

COTR Signature:

COTR Decision and Date: □ Approve □ Disapprove

CSS Name: CSS Receipt Date: □ Approve □ Disapprove

COTR Date to Vendor: CCFS Estimated Treatment Start Date:

CHANGES TO ORIGINAL AUTHORIZATION

Change: □ Additional Services

□ Deobligation

Reason(s):

COTR Name:

COTR Signature:

COTR Decision and Date: □ Approve □ Disapprove

Vendor: OFM Decision and Date: □ Approve □ Disapprove

Date to Vendor: Comments:

Revised 04/08/10