SOMB Request For Treatment Modifications

Provider Name*

First NameLast Name

Adult Provider Approved Statuses (Select All That Apply)*

1. Please input Client's Index Offense and Date of Conviction.*

2. Please input Client's current length of time in treatment*

Indicate Client Overall Risk Level

Indicate Client Overall Need Level (Dynamic Risk/Need)

3. Please select which of the following have occurred, if any, that are present and drive the need for standards modifications

Evaluation Recommends treatment other than Offense Specific Treatment under the StandardsCourt Modification/Court OrderIndividual Client's Risk/Needs

4. What Section(s) of the Standards are you requesting to Modify?

5. List the Standard and Standard number for which you are requesting to modify.

6. Describe the proposed modifications*

7. Describe how the proposed modification will address victim and community safety.*

8. Describe the time frame for the use of the proposed modification.*

9. Please cite the supporting evidence for the proposed modifications from the evaluation, court order or justification for standards modifications. (i.e. specific recommendation from eval, court order)*

Has the team addressed Court Orders, Protection Orders and/or Supervision Conditions which may impact ability to modify treatment? (Please attach verification/documentation)*

YesNo

Providers must collaborate with all members of the CST. Letters of support or concern are highly recommended to be submitted with the modification request from each of the following. (See numbers 10 and 11)

*Note: If a member of the CST is unable or unwilling to provide a letter regarding this request, please attach documentation of the attempt to gather the information or how any known information was incorporated into the modification request.

10. Please attached verification of consensus by the Supervising Officer (if available)

11. Written verification that CST consensus has been obtained for this proposal (Victim Representative - may include a letter from the victim)*

SOMB Staff will perform an initial review of the request. If the request is not acceptable, the Staff will work with the Provider to modify and address any questions or concerns. The ARC will then review the Standards Modification Request. If the request is acceptable and does not pose a safety risk, the ARC has been authorized by the Board to approve the request. If requests do not receive a unanimous vote to be approved by the ARC, providers may be required to submit a formal variance. If approved, the ARC will ratify the Standards Modifications Request and create a plan for conducting periodic reviews and any necessary documentation required for those reviews. The Provider will be notified in writing of the decision to approve or deny the request.

The SOMB has the authority to set forth specific program conditions during the time frame of the proposed variation. This may include requiring the provider to submit to periodic documentation to the SOMB regarding how the Standard variation is working, identifying any benefits and/or challenges.

Signature*

Date*

Date

SOMB Request for Treatment Modifications