Referral Form

  • Client Information

  • Date Format: MM slash DD slash YYYY
  • Current Sexual Offense(s):

  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • OffenseAge of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Prior Sexual Offense (s)

  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Age of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • OffenseAge of VictimChild Victim(s) MChild Victim(s) FAdult Victim(s) MAdult Victim(s) F 
  • Risk Assessment Scores

  • ScoreDate 
  • ScoreDate 
  • ScoreDate 
  • ScoreDate 
  • Treatment History

  • Alternative CBISO
    This group meets weekly and is designed for individuals who are lower cognitive functioning, seriously mentally ill, or who have another disabling condition that requires modified treatment.
  • CBISO
    This group meets weekly and is designed for individuals who have not completed or failed sex offender treatment elsewhere. This program will also fit the needs of individuals who have completed treatment but failed to demonstrate mastery of the material. This Group is designed for individuals who are Moderate to High Risk. (some Level III, Level IVA, Level IVB)
  • Advanced CBISO
    This group meets weekly and is designed for individuals who have completed CBISO, have demonstrated mastery over the material and who need modification to their Success Plans to fit community-based needs.
  • Aftercare Phase II
    This group meets twice per month and is designed for individuals who have completed treatment, have demonstrated mastery over the material and are ready for a reduced level of care, yet need to target specific dynamic risk factors before moving into a monthly treatment program.
  • Aftercare Phase III
    This group meets monthly and is designed for individuals who have completed treatment, have demonstrated mastery over the material, and who are ready for a reduced level of care.
  • Individual Therapy
    This is designed for individuals who require individual care, usually for extreme and unusual circumstances. Do NOT check this box for individuals who need to be seen in addition to one of the groups above. Check this box only if you are recommending individual programming instead of any of the groups listed above.
  • Low Intensity Treatment
    This Group meets weekly and is designed for individuals who present with a Low to Moderate risk to reoffend, who non the less have identified criminogenic needs to be addressed. (Level II and some Level III).
  • Education/Boundary Work
    This short-term group meets weekly and focuses most heavily on providing education as it relates to consent, boundaries, human sexuality, gender role stereotypes, thinking errors, different types of denial, importance of positive peer groups, development of pro social healthy leisure and other areas as appropriate. This group is appropriate for individuals whose risk is below average (Level I, possibly some Level II).
  • Period of Supervision

  • Date Format: MM slash DD slash YYYY
  • Thank you for your referral.
    To expedite the process, please ensure you send the completed form along with supporting documentation. Missing information will delay processing. All referrals can be directed to STAND CEO, Dr. Stacey Benson at stacey@standnorthdakota.com. Please call 701-630-6100 with any questions. *