FINAL CLIENT DISCHARGE SUMMARY CASE#: P.O./C.W.: PHONE: FAX: REPORT BY: CELL: TX START DATE INTAKE DATE:

CLIENT: ADDRESS:

PHONE: D.O.B.: REPORT DATE:

CURRENT LEVEL:_____ original___ changed___ DATE OF LEVEL CHANGE:______ REASON FOR CHANGE:________________________ __________________________________________________________________________________________________________________________________________ SESSIONS ATTENDED:

SESSIONS MISSED:

SESSIONS EXCUSED:

COUPLE STATUS: ____ New Partner ____Same Partner ___RTO/PO ___Temporary Separated __Together ___Child Visitation PROGRAMS ATTENDED: ___ DV TX ___ RELAPSE PREVENTION ___PARENTING ___ANIMAL CRUELTY ___TRAUMA TX others:

DESCRIPTION OF THE INDEX OFFENSE AND CASE

IDENTIFIED UPON ENTRY: CRIMINOGENIC NEEDS:

Anti-social personality Anti-social attitudes and values Anti-social associates Family dysfunction Poor self-control, poor problem-solving skills TRAUMAGENIC NEEDS: Child victim of emotional abuse Grief

DV Victim

Adult sexual abuse

Child abuse Theft Substance abuse Lack of employment/employment skills/low ED Impulsive behavior tendencies

Witness to animal abuse Natural Disaster

Child physical/sexual abuse Combat/gang brutality

PSYCHOGENIC NEEDS:

Histrionic Narcissistic

Compulsive Sadistic

Schizoid Obsessive

Aggressive Avoidant

Substance Dependant Borderline

Bi-Polar Depressed

Summary of DVRNA Significant & Critical Risk Factors: A – Prior DV Convictions (C) B – Substance Abuse E – Weapon Use/Threatened Use F – Criminal History (B) I – Family Violence (child/family) J - Attitudes condone/support M – Unemployed N - Pro Criminal social influence DVRNA Results: DV Treatment Intensity Level Level A IDENTIFIED DURING TREATMENT: CLIENT’S PRESENTED ISSUES/CONCERNS/ ATTITUDE: CLIENT’S PARTICIPATION IN TREATMENT: Client participates actively and appropriately Client participates actively Client reluctantly participates/Participates only when called upon Client resists participation even when called upon Client does not participate even when called upon Client is discharged unsuccessful

C – Mental Health Issue G – Obsession w/ Victim K – Prior DV Treatment Level B

Level C

D – Suicidal/Homicidal H – Safety Concerns L – Separated from victim in last 6 months. SCORE:

Page 1 CRITICAL INCIDENTS/NEGATIVE & POSITIVE: 1. employment 2. arrests/ conviction of pending cases/abusive incidents (non-arrests) 3. problems with staff, probation, other counselors 4. monitoring failure: UA’s, BA’s, Ankle Bracelet 5. reductions of risk 6. other CORE COMPETENCY PROGRESS Comments: (low=Unacceptable/Serious Concerns, Med=Average/Met medium expectations, High= Excellent/Exceed Expectations Consistently)

Demonstrated Stabilization Non-Blaming Attitude *stopped abuse to kids M * understands impact of abusive behavior on kids Parenting Skills (Completed Parenting) M * identifies & properly addresses kids needs *properly arrange for visitation & be on time * fulfills $ obligation to kids Demonstrated Knowledge of DV * appropriately discusses the needs of the children with the other parent Acknowledgment of past abusive behavior Accepts Feedback Self-Management Tools Gives Feedback Impact of Violence Accepts Corrective Changes Demonstrates Congruent Beliefs Utilizes Good Communication Skills Ability to be empathetic when in conflict Recognizes High Risk Behaviors RECOMMENDATIONS: ___ DISCHARGE COMPLETED ____DISCHARGE UNSUCCESSFUL ___ADMINISTRATIVE DISHARGE Additional treatment or containment measures recommended: MTT COMMENTS:

(Each member is asked to sign this sheet and return page 2 to CCA)

PROBATION OFFICER:______________________________AGREES WITH REPORT____DISAGREES WITH REPORT____ STATEMENT:_______________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________ VICTIM ADVOCATE: ___________________________AGREES WITH REPORT____DISAGREES WITH REPORT____ STATEMENT:_______________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________ OTHER MEMBER:______________________________AGREES WITH REPORT____DISAGREES WITH REPORT____ STATEMENT:_______________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________ OTHER MEMBER:______________________________AGREES WITH REPORT____DISAGREES WITH REPORT____ STATEMENT:_______________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________ OTHER MEMBER:______________________________AGREES WITH REPORT____DISAGREES WITH REPORT____ STATEMENT:_______________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________

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