US & SD, Imperial Probation or Liberty Health
Offender Referral Form
Probation Officer's Information
Date
-
Month
-
Day
Year
Date
Agency Supervising Client
US Federal Probation
San Diego County Probation
Imperial County Probation
Liberty Healthcare
PO's last name
*
PO's email address
*
to receive copy of this referral
Client's information
Type of exam requested
*
Maintenance
Maintenance (Re-test from previous failed exam)
Sexual History
Sexual History (Re-test from previous failed exam)
Instant Offense
Clients Name:
*
First Name
Last Name
Client's PACTS # or ID #
number
Client's Offense
ie. CP, Solicitation, etc.
Date of last polygraph if applicable
-
Month
-
Day
Year
Date
Client probation restrictions
Contact with minors
No contact with minors without PO approval
Yes, can have contact with any minor
Access to internet capable devices
Monitored devices or pre-approved devices only
Yes, client can use any internet device
Allowed to view sexually explicit materials
No, not allowed to view sexually explicited materials
Yes, can view sexually explicit materials
Consume alcohol
Not allowed
Yes
Request relevant polygraph topics (select 2 or 4 ONLY)
*
Use of DEVICES connected to the internet
Viewing sexually explicit materials (X-rated only)
Being alone with a minor
Physical contact with a minor
Visiting websites or apps for sexual purposes (porn sites, dating sites)
Visiting adult establishments (ex. strip clubs, sex shops)
Visiting social media websites or apps (FB, Insta, Twitter)
Paying for sexual stimulus (prostitutes, phone sex, live video, etc.)
Sexual contact with others
Illegal drug use
Leaving the county without permission
Masturbating to any thoughts or fantasies of minors to orgasm
Any Alcohol Consumption
Examiner's choice based on pre-polygraph interview
N/A, this is a Sexual History Exam
Other
Please enter any other relevant information you would like us to know.
If a co-payment is required by Client, type in the amount?
*
Full Exam Price
No co-payment required
Other
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