SEX OFFENDER SUPERVISION COMPLIANCE MONTHLY REPORT FORM YAMHILL COUNTY

Sex offender treatment agency:________________Location:_______________________Therapist name:_________________________

Date last attended treatment: / / Completed: Y or N List any missed treatment appointments:

Date of your last polygraph? ___/___/___ Pass[ ] Fail[ ] Inconclusive[ ] Polygraph examiner name:______________________

Have you passed a full-disclosure polygraph? YES[ ] NO[ ] If yes, date you completed: / /

Who do you spend time with?_______________________________________________________________________________________

Who are the people that support you with your goals? ____________________________________________________________________

When and where have you had contact with children?_____________________________________________________________________

Tell me about any arguments you’ve had:____________________________________________________________________________________________________

What has caused you stress and how did you cope?

Describe your sexual behaviors:_______________________________________________________________________________________

In what ways have you used pornography?______________________________________________________________________________ What type?___________________________________________________________________________________________________

How do you manage sexual urges?____________________________________________________________________________________

Who have you had sex with during the last month?____________________________________________________________________

Name of current partner/significant other?

How do you feel about supervision?___________________________________________________________________________________

I would like to talk to my PO about:___________________________________________________________________________________

I would like to talk to my therapist about:_______________________________________________________________________________

I would like help with the following goals:______________________________________________________________________________

Recent alcohol or drug use (including prescription drugs):­­­­­­­­­________________________________________________________________

Alcohol and drug treatment agency:________________________ Location:_____________________Counselor name:_________________

Date last attended treatment: / / Completed: Y or N List any missed treatment appointments:

Mental health treatment agency:___________________________ Location:_____________________Counselor name:_________________

Date last attended treatment: / / Completed: Y or N List any missed treatment appointments:

What contact with police have you had since your last monthly report?________________________________________________________