Domestic Violence Treatment Progress Assessment (DVTPA) Monthly/Quarterly Summary Treatment Agency: ___________________________ Therapist: Client Name: ____________________ DOB: __________ Probation Officer: Treatment Start Date: ________________ Treatment Level: Month Review Date: ____________________ Quarterly Date Reviewed with Client:

Dates of attended treatment sessions:

IMMEDIATE CONCERNS: 1. 2. 3. 4. 5. 6. 7. 8.

SCORING: Check if an issue

Not Accountable with community supervision and treatment conditions Using alcohol or illicit drugs Not maintaining stable employment Not maintaining stable living arrangements Not Compliant with psychiatric and medical recommendations Hostility Stalking dynamics/obsession with the victim Suicidal/Homicidal

*Any check-marked areas creates immediate safety concerns for victim and an increase in risk for offender. Item requires immediate action to mitigate if possible by the M.T.T. and increase in supervision.

Scoring Guide Codes: 0=No 1=In Progress 2=Yes/Competency Completed N/A=Not Applicable Client Therapists’ CLIENT COMPETENCY AREAS Self-Report Score Scoring (Based on Observation, Program Assignments and Offender Report)

1. 2. 3. 4. 5. 6. 7.

Actively participates in treatment. Confronts others appropriately in group. Commitment to elimination of abusive behavior. Eliminates manipulative behavior. Completed personal change plan. Demonstrates development of empathy. Accepts full responsibility for offense and abusive behavior. *Denial Level (If applicable)

8. Understands pattern of power and control issues. 9. Does not view themselves as the victim. 10. Accepts consequences of abusive behavior. 11. Challenges cognitive distortions. 12. Define types of violence. 13. Identifies & manages personal pattern of violence. 14. Understanding of inter-generational effects of violence. 15. Uses appropriate communication skills. 16. Offender understands and uses “time-out.” 17. Recognizes financial responsibility. 18. Not engaging in any known forms of violence & abuse. 19. Understands distorted view of self, others & relationships. 20. Identifies chronic abusive beliefs about victim and thought patterns that support abusive behavior 21. Uses pro-social community supports. 1  Revised 10‐2‐12 Davies & Associates                   FORM MAY BE COPIED WITHOUT ALTERATIONS, FOR CONTACT INFORMATION CALL (970) 353‐0422

22. Understands cycle of violence. 23. Positive parenting skills with children. (living with biological children) 24. Demonstrates appropriate interaction with children and partner in a co-parenting or step-parenting situation (Client a step-parent or visiting parent) 25. Understands healthy sexual behaviors & consent. 26. Other: 27. Other:

Comments from Competency Areas: Number Comments:

STRENGTHS: 1. 2. 3. 4. 5. 6. 7.

Client Self- Report

Therapist scoring

Comments

Pro-Social Friends Social Activity Spirituality Happiness Creativity Fun Time/Hobbies Health

Risk concerns for this month/review period:

Counselor Comments:

Please indicate other services provided, agency name and frequency: U.A. Color: ____________ B.A. Color: ___________ Monitoring Location: Scram: _______________ ETG: ________________ Antabuse: Mental Health Counseling: ______________________ Substance Counseling: Other Services:

Primary Therapist

Date

2  Revised 10‐2‐12 Davies & Associates                   FORM MAY BE COPIED WITHOUT ALTERATIONS, FOR CONTACT INFORMATION CALL (970) 353‐0422