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About S.T.A.N.D.
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Referral Form
Client Information
Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Gender
Current Sexual Offense(s):
Continuous Sexual Abuse of a Child
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Corruption or Solicitation of a Minor
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Deviant sexual act
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Failure to register
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Fornication
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Gross Sexual Imposition
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Incest
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Indecent exposure
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Luring Minors by Computer
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Sexual Abuse of Wards
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Sexual Assault
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Sexual Exploitation by Therapist
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Sexual Imposition
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Surreptitious Intrusion
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Other (specify)
Offense
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Prior Sexual Offense (s)
Continuous Sexual Abuse of a Child
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Corruption or Solicitation of a Minor
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Deviant Sexual Act
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Failure to Register
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Fornication
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Gross Sexual Imposition
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Incest
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Indecent Exposure
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Luring Minors by Computer
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Sexual Abuse of Wards
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Sexual Assault
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Sexual Exploitation by Therapist
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Sexual Imposition
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Surreptitious Intrusion
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Other (specify)
Offense
Age of Victim
Child Victim(s) M
Child Victim(s) F
Adult Victim(s) M
Adult Victim(s) F
Risk Assessment Scores
LSI-R
Score
Date
Static 99-R
Score
Date
Stable 2007
Score
Date
Acute
Score
Date
Estimated Level of Risk
Low
Moderate
High
SORAC Risk Level
Low
Moderate
High
Has this individual been referred for Civil Commitment?
Yes
No
Is this individual on Community Civil Commitment?
Yes
No
Treatment History
Program:
Length of Treatment
Cooperation in Treatment
Poor
Fair
Good
Excellent
Program:
Length of Treatment
Cooperation in Treatment
Poor
Fair
Good
Excellent
Program:
Length of Treatment
Cooperation in Treatment
Poor
Fair
Good
Excellent
DSM Diagnosis (if available):
Additional Comments:
Please check which program you are referring this individual for:
Alternative CBISO
CBISO
Advanced CBISO
Aftercare Phase II
Aftercare Phase III
Individual Therapy
Low Intensity Treatment
Education/Boundary Work
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).
Documents Needed for Referral
Sex Offender Assessment
SO Treatment Discharge Summary
Criminal Judgement
Appendix A
PSI
Police Reports/Incident Reports
Other
Supporting Documentation
Period of Supervision
From:
To:
Officer
Referral Completed By:
Agency
Date
Date Format: MM slash DD slash YYYY
Phone
Email
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. *
About S.T.A.N.D.
About Us
Our Team
History of S.T.A.N.D.
Education & Public Policy
What we do
Fact Checking & Commonly Asked Questions
Resources & Training
Resources & Training
Training for Providers
Training for the Community
Helpful Links
Contact