A Better Way Counseling Service, LLC

A Better Way Counseling Service, LLC
Assessment/Evaluation Summary Results
Date of Assessment:*

MonthDayYear
Date
Client Legal Name: *

First NameLast Name
Client Date of Birth: *

MonthDayYear
Date
Client Phone Number:*
Client Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral Information
Referral Name:

First NameLast Name
Referral Company:
DOC, Program Name, DCYF, Etc.
Additional Referral Name:

First NameLast Name
Additional Referral Company:
DOC, Program Name, DCYF, Etc.
Biopsychosocial Summary
Domain 7 - Standardized Tests and Results
The Ontario Domestic Assult Risk Assessment (ODARA) is a good actuarial instrument used to predict the likelihood of a future domestic assault. This instrument measures 13 factors such as criminal history, children in the relationship, the vulnerability of the victim, and substance use. The client scored:
Percent Client Scored on (ODARA):
%
The client scored in the following risk range:

Low RiskMedium RiskHigh RiskDid not use ODARA
Ontario Domestic Assault Risk Assessment (ODARA) score:
The Violence Risk Appraisal Guide (VRAG) is a good actuarial instrument used to predict the likelihood of future violence, in general. This instrument measures 12 factors such as criminal history, personal and family of origin addiction patterns, family of origin cohesion, childhood aggression, etc.
The client's (VRAG) risk:

Low RiskMedium RiskHigh RiskDid not use VRAG
Violence Risk Appraisal Guide (VRAG) score:
The Domestic Violence Inventory (DVI) is a multidimensional, self-report test used to assess male and female adults accused, or convicted, of domestic violence. The DVI is primarily used in courts, probation departments, counseling agencies, and treatment programs. The DVI is a domestic violence offender, risk assessment tool. In addition to evaluating an offender’s predisposition for violence, per se, the DVI screens adjunctive factors, such as offender truthfulness, substance (alcohol and other drugs) abuse, controlling tendencies, and stress management skills. These contributing factors (criminogenic needs) are represented in the DVI as scales (measures)
DVI Truthfulness Scale

Low RiskMedium RiskProblem RiskSevere Problem Risk
DVI Violence Scale

Low RiskMedium RiskProblem RiskSevere Problem Risk
DVI Control Scale

Low RiskMedium RiskProblem RiskSevere Problem Risk
DVI Alcohol Scale

Low RiskMedium RiskProblem RiskSevere Problem Risk
DVI Drug Scale

Low RiskMedium RiskProblem RiskSevere Problem Risk
DVI Stress Coping Abilities Scale

Low RiskMedium RiskProblem RiskSevere Problem Risk
DVI Comments:
Acute/Critical Assessment Factors
Previous incidents of physical assaults causing injury, sexual assaults, strangulation, or previous reported incidents toward more than one partner*

YesNo
Previous use or threats with weapons against an intimate partner or family member*

YesNo
Stalking or holding a victim captive*

YesNo
Physical, sexual, or assaultive violence against children, pets, or elderly*

YesNo
Homicidal/suicidal ideation or threats in last 12 months*

YesNo
Repeated violations of probation, no contact orders, protective orders, or similar orders*

YesNo
Medium or high level of psychopathy*

YesNo
Police Report and/or Collateral Summary
Summary report of current/past police report, incident report, or any collateral- including the presence of children and the client's comments:*
N/A if not applicable
Did not receive collateral:

I waited 3 weeks for collateral and did not recieve anythingThere wasn't a police reportOther
Recommendations
My recommendation is based on the following sources of information:*

Interactions with client/client self-reportPolice Report(s)Court DocumentsSubstance Abuse Assessment and/or TreatmentMental Health Assessment and/or TreatmentCollateral information from referral sourceCollateral information from victim/friend/family contactODARA ScoreVRAG ScoreP-SCAN ScoreOther
Level of accountability:*
Readiness to change:*
Abusive behaviors to target in treatment:*
Treatment Recommended:*

No TreatmentAggression Control Workshop Level 1Aggression Control Workshop Level 2Anger Management 26 weeks with reviewAnger Management 36 weeks with reviewAnger Management 52 weeks with reviewBased on and in consideration of all the information gathered in this assessment, I concluded that this client has demonstrated behaviors that are consistent with a pattern of domestic violence. In compliance with WAC 388-60B, the client should complete a minimum of 26 weekly sessions of the Domestic Violence Intervention Treatment Program (Level 1 DVIT)Based on and in consideration of all the information gathered in this assessment, I concluded that this client has demonstrated behaviors that are consistent with a pattern of domestic violence. In compliance with WAC 388-60B, the client should complete a minimum of 36 weekly sessions of the Domestic Violence Intervention Treatment Program (Level 2 DVIT)Based on and in consideration of all the information gathered in this assessment, I concluded that this client has demonstrated behaviors that are consistent with a pattern of domestic violence. In compliance with WAC 388-60B, the client should complete a minimum of 52 weekly sessions of the Domestic Violence Intervention Treatment Program (Level 3 DVIT)Based on and in consideration of all the information gathered in this assessment, I concluded that this client has demonstrated behaviors that are consistent with a pattern of domestic violence. In compliance with WAC 388-60B, the client should complete a minimum of 78 weekly sessions of the Domestic Violence Intervention Treatment Program (Level 4 DVIT)Aggressive Behavior Management for a minimum of 26 weeksAggressive Behavior Management for a minimum of 36 weeksAggressive Behavior Management for a minimum of 52 weeksOther
Treatment level rationale:*
If applicable, diagnosis given:
Diagnosis:
Any other diagnosis that isn't listed
Other recommended treatment referral(s):
Parenting plan, Mental health assessment, substance abuse
Is child support required?*

YesNo
I, the attending clinician, am signing to confirm that I completed this assessment by meeting face-to-face with the above-named client. A copy of this assessment was sent to all other required recipients and will be kept on record for 7 years.
Today's date:*

MonthDayYear
Date
Name of Attending Clinician: *

First NameLast Name
Title/DVIT Staff Level of Clinician:*
Clinician Signature*

Clear
Should be Empty:

A Better Way Counseling Service, LLC

Assessment/Evaluation Summary Results

Referral Information

Biopsychosocial Summary

Domain 7 - Standardized Tests and Results

Acute/Critical Assessment Factors

Police Report and/or Collateral Summary

Recommendations