Sex Offender Treatment Request Form Page 3
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4*When was the last time these behaviors occurred? _________________________________________________
__________________________________________________________________________________________
Do these behaviors occur in the school? _________________________________________________________
__________________________________________________________________________________________
*Is the school involved in current treatment plan? Describe coordination with the school. ___________________
__________________________________________________________________________________________
Is the member involved with Special Ed? __________________________________________________________
__________________________________________________________________________________________
*Baseline (for concurrent review, describe movement toward baseline): __________________________________
__________________________________________________________________________________________
*DSM-5 Diagnoses (Axis I or II and comorbidities) ___________________________________________________
(Primary dx must be appropriate for level of care): __________________________________________________
*Urine Drug Screen (UDS) & Blood Alcohol Level (BAL) results: _________________________________________
Treatment History: ___________________________________________________________________________
__________________________________________________________________________________________
*Treatment plan (include behavior plan, parenting work, family interventions): _____________________________
__________________________________________________________________________________________
*Specific to behavior plan, what assistance will family/guardians need in order to maintain behavior plan to
include monitoring of the member upon discharge? _________________________________________________
__________________________________________________________________________________________
*Medications:
*Medication adherence? Barriers to adherence? ___________________________________________________
__________________________________________________________________________________________
*If concurrent review, what progress has been made in reducing inappropriate behaviors? ___________________
__________________________________________________________________________________________
*If concurrent review and no progress has been made in reducing inappropriate behaviors, how will the treatment
plan be changed? ____________________________________________________________________________
__________________________________________________________________________________________
This facsimile contains privileged and confidential information intended only for the use of the specific individual or entity named above. If you or
your employer are not the intended recipient of this facsimile (or an agent responsible for delivering it to the intended recipient), you are hereby
notified that, any unauthorized distribution or copying of this facsimile for the information contained in it, is strictly prohibited. If you have received
this facsimile in error, please immediately notify the person named above by telephone and return the original facsimile to the above address via
the U.S. Postal Service. Thank You.
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