Beruflich Dokumente
Kultur Dokumente
Collateral Contact:
Summary of Contact:
On 8/9/06, TC from the SM. His cell phone number IS (b)(6) . SM reported that he went back to court. SM informed CM
that he was convicted in court and must enroll in a mandatory certified 52 week DV group. SM stated that he will enroll at
Community Conneclions. SM reported that he must do a 120 day work furlough program. where he will sleep at the site, but
be allowed to go to work dunng the day SM related that there is another court hearing on 8!16106 to address the TRO.
SIGNATURES
--·-----···-
(b)(6)
Signature of Provider: Date of Signature: 81912006
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Collateral Contact:
Summary of Contact:
On 812/06. TC from (b)(6) Case was discussed. SM has been released from jail and is at his command.
SM has a court heanng tomorrow and must attend AA meetings CM requested that command have SM to contact CM to set
up an intake interview to discuss the incident. CM explained that SM is a FAP treatment failure. (b)(6) Nill have the
SM to contact CM
On 8/2/06, TC from the SM. His contact number is (b)(6) . The Pnvacy Act was discussed, but not signed. SM related that
he had another alcohol related DV incident on 712'2./Uo. AUM stated that he had been drinking a lot of beer and Tequila. He
stated that h1s ADW was in the car and was going to leave. SM related that he took the key out of the ignition. ADM reported
that he saw a text message on ADW's cell phone form a man. ADM related that he grabbed ADW by the hair and threw her
against the garage door. ADM d1sclosed that he also choked ADW. He stated that he picked her up and asked if she was
cheating on him. ADM related that h1s ADW told him that she was not cheating. ADW ran around the car. Neighbors heard
the noise and came to the house. ADM related that all he recalls is one male neighbor holding him. ADM stated that his ADW
ran into the house and called the police. ADM was arrested and spent one week in jail. ADM related that his child was in the
house. ADM related that he has been ordered to attend 3 AA meeting per week. He has a court hearing tomorrow 8/3106 at
0800. ADM has been informed that FAP does not have a court approved certified DV program and will not offer h1m treatment
due to bemg a FAP treatment failure. SM related that he was already attending a 52 week OV group in the community
voluntanly. SM related that he was released from Jail on a SRO (Supervised Release Order) and someone from his command
must escort h1m to his meet1ngs. ADM agreed to come in to FAP after h1s court hearing on 8/3/06 at 1400
On 8/2/06, CPS report via fax due to child being in the house during the incident.
On 8/3/06, TM from SM. He left a message informing CM that he could not come in for an intake appointment today, because
the court continued his case until Monday 8/7/06.
SIGNATURES
Signature of Provider: (b)(6) Date of Signature: 8/7/2006
Collateral Contact:
Summary of Contact:
CRC case closed 4i1/08
Closing status: unresolved. SM IS to complete 52 weeks in the community. Ship has been deployed, unable to complete
classes
2486 completed
· Letter drafted .
. Family previously notified of plan.
SIGNATURES
1pollateral Contact:
'~ummary of Contact:
~~On 5/7/08, case was presented at CRC for a subsequent inc1dent of DV. The CRC voted to substantiate this subsequent
I cident. ADM was identified as the pnmary offender of spouse abuse based on the interview w1th ADM. interv1ew w1th the
iF, the med;cal mpmt. pohce ceport and the pcepondecance of choical intocmation as well as the ADM pleadmg gwlty to
alation of the RO and property destruction. CRC is recomrnencflng to close the case as a trestment fa1lure due to ltlG ADM
ntmued abusive behsvior despite h1s attendance at 26/52 group sessions tn his DV group in the community, a Page 13 and
. . Admin Review ADM w111 have to adhere to the court requirements.
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fAP Clinical Contact Note
(b)(6)
~ase Number 25874 Client Name:
~
(b)(6)
F:;ontact Date: 1!2812008 Clinical Provider:
--- -- --
[rime Spent: 0.5 Type of Contact: Phone
~ollateral Contact:
·--
~ummary of Contact:
'On 1/28/08, TC to the SM. CM contacted the SM to get another update on his court hearing. SM informed CM that his court
ial heanng that was onginally scheduled for 1/22/08 was pushed back to 2119108. SM reported that he still plans to got to
ial if necessary and 1s willmg to take ttle stand. SM continues to deny the abuse. SM repor1ed that he can not continue to
ttend the DV group Ill the community until this court process is concluded. SM has completed 26/52 DV group sessions. SM
ipformed CM that ADW tried to get the court to make htm pay her money for the two cars that she refused to share With him.
M explained that they took out two car loans. but ADW chose to keep both cars SM reported that the Judge denied her
~quest. SM explamed that ADW refused to make arrangements w1th him to let htm have one of t11e cars. SM statecl that he
ad to go out and buy htmself another car. SM reported that ADW is trymq to sale one of the cars. SM reported that both of
heir commands are aware of what's been going on. SM mformed CM that since both he and ADW are m tho military and
. pce1ved the same pay and have no children, the court and the1r commands am not reqUiring him to pay his ADW any money
t this time. SM reported that h1s Chtef will accompany him to court on February 19th. CM requested that his Chief nottfy CM
. f the outcome of the court hearing if he is unable to do so. SM 1ntormed CM that the divorce is still pending. CM informed the
M that the case would go back to CRC in March 2008 for a determmation.
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~AP Clinical Contact Note
(b)(6)
Case Number 25874 Client Name:
-··-------
Clinical Provider: (b)(6)
' ontact Date: 9/1 0/2007
( ollateral Contact:
ummary of Contact:
(b)(6)
pn 9/10/07, TC to the ADM at ADM reported that he has completed 26/52 group sessions. He reported !hilt he
~ps learned a lot from the group and is utilizmg his new skillS. ADM stated that he uses "I" statements. and is more aware of
t\ s anger triggers. SM agreed to drop off a copy of h1s progress report after he returns to the SO area at the end of
$9ptember 07. He reported no new problems in the marnage.
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-------
~ ignature of Provider: (b)(6) I Date of Signature: 9/10/2007
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fAP Clinical Contact Note
(b)(6)
, ~ase Number 25874 Client Name:
---·~-·
Collateral Contact:
---·~ -
Summary of Contact:
On 1/5/06, OV With ADM. He reported th<'lt he and his ADW are doing fine. ADW had the stay-away order lifted today. There
as been no new incidents of abuse ADM related that he and his ADW plan to work on the marnage. ADM dropped off a
opy of the progress report for his court ordered DV ~Jroup. ADM related that eh really entoys h1s group which meets on
paturdays. He related that he ts learning a lot of new skills.
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rAP Clinical Contact Note
~ ase Number 25874 Client Name: (b)(6)
--
Pontact Date: 12/13/2006 Clinical Provider: (b)(6)
-
ime Spent: 0.25 Type of Contact: Other
'~ollateral Contact:
-
· ~ummary of Contact:
On 12/13/06, case was presented at CRC and substantiated. ADM was ident1fled as the pnmary offender of spouse al)USe.
He has been court mandated to attend a 52 week DV group 111 the community.
')n 12/13/06, TC to the SM at (b)(6) (cell phone). CM left a vo1ce message regardlllg the outcome of CRC and requested
return call.
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:ollateral Contact:
H-----------------------------------------------------------------------------------~
, Summary of Contact:
SM called to state that he was called m by h1s DAPA to undergo his screening. He states that they are opening the casn up
nd he was mstructed to call th1s CM. CM explamed that this IS routme case management and wanted to touch bases before
e deployed wt1h USS NIMITZ m Apnl for 6 mos. SM states that ho 11as attended 6-7 DVRP classes, as h1s sh1p's schedule
llows. He attends at 1730 on Thurs. He went to court serv1ces and was told that he d•d not need to attend AA or have
' lcohol treatment. SM was told that FAP recommended the SARP eval smce there was concern about alcohol In !he InCident
nd the court saw it necessary to mitially recommend AA.
M states that he and spouse are doing well, however she is also deployed with H1e USS BOXER. She left m February, Their
mos old baby 1s with h1s step-mother in (b)(6) anc.! will share w1th ADF's sister in IllinOis. SM states that he and ADF-
f ed for sponsored relocation but it was den1ed due to being f:rsl terrn sailors. SM states his s1ster m law wrote an article in
l e paper about caring for their baby and now (b)(6) is trying to reach them
I~ M states that it has been stressful to be away from one anotl1er and be separated from the baby. THey had some pay
1r oblems but have worked through 1!.
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Collateral Contact:
-
Summary of Contact:
SM attended the FAP Educational Session on Fn. He is reported to have been an asset to the group and motivated for
~ssistance i
~M called Mon. 11/20. and states that h1s command consulted w1th spouse's command and lifted the MPO AOF has returned
rom her parent's home.
~M reports he has applied the I slfltements learned 1n Ed Session and would like marital counseling. He was referred to
~Jiitary One Source and approved to receive services. SM would like to attend the Navy's Men's Group and a court letter was
rovided to show the judge at his next court date. Since he is mandatecJ to attend a community 52 wk program. SM was
dvised to sign up and start until the Judge can consider his request.
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umber Appendage Note
- jP,ov,der'; Nan~e Date
-
SM also states that he has an appmt with Ship's Psychologist for a (b)(6) 11/20/2006 4:18:00
depression/medication evaluation. PM
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FAP Clinical Contact Note
(b)(6)
Case Number 27076 Client Name:
~
~
Collateral Contact:
-- --
Summary of Contact:
TIC to CFAR, (b)( 6 ) (b)(6)
of the Nimitz. Informed CFAR that SM . has not been attendrng group in the
•ommunrty and has not bePn in contact with CM as he was asked to after the recent court heanng. CFAR will forward
nforrnalion to (b)( 6) who is SM's CM. CMC's # is (b)( 6 )
--~
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IFAP Clinical Contact Note (b)(6)
Case Number 27076 Client Name:
(b)(6)
---------
Contact Date; 1/7/2008
~-···-------------1
Time Spent: 0.25
Collateral Contact:
Summary of Contact:
SM contacted CM concerning status of tlrs lx. 1n the cornmumty SM stated that he had been attending a 52 week group as
ourt mandated but found he was not getting anything out of it. SM stated that he has been back from deployment lor approx I
:> months and has not attended any group sessrons. SM stated that he would like to attend group on base. CM told SM that ·
he decrsron about where he is to attend group and for how many sessions is up to the cour1. SM stated that on the lollowmg
~ay he had to go to court to update the court on h1s progress CM told SM to call CM after the court hearing to update CM on
ourt proceeding.
U:
Collateral Contact:
Summary of Contact:
Recetved phone call from SM who stated that he has completed 14 of the mandated 52 week State of Califorma DV
program although ts ftndmg it dilftcult to continue due to fam,ly and military responstbililles. SM stated that next court date is
or 1 JAN 07 and is seeking a leiter stating that he may attend the 16 DV Men's program at the FAC. Informed SM that 1! may
pe unlikely that his court date is scheduled for 1 JAN 07 and that th1s should be verified. Also recommended that SM obta1n a
etter from his Command wtth respect to m11itary responstbilitles mak.ing 11 t1Jfficult to contmue wtth the court mandated
program. Informed SM that his CM will return 31 DEC 07 and provided contact phone number.
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I·A-::-p-'-:-p_en..:.d. :.a.::cge.:. .·7""N.:.ot..::.e_ _ _-:---~--:--:-----------t1Provider's Name
lt.IJ-'-Iu..:.m..:.b..::.e_rt: ]Date
't-_ ___.1_iD_a_te_c..:..o_n..:.ta_i,_,e..:..d..:.i_n_n..::.o~te.:...s.:...h...::o..:::.u:.::ld...:b:..:e_1.:...J:.:.A..:..N...:.._::_0.:..8..:..m:.::s:.::te:.::a:.::d...:o:.:..f..:..1..::.J.:_A~N.:...C::..:.l7..:..._---~.1 (b )(6) [12/28i2007 4:46:00 PM _j
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Collateral Contact:
Summary of Contact:
· Group Note/Participation Form
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jFAP Clinical Contact Note
(b)(6)
·Case Number 36618 Client Name:
(b)(6)
Contact Date: 7/17/2007 Clinical Provider:
Collateral Contact:
Summary of Contact:
Group Note/Participation Form
pOMMENTS or SUMMARY:
(b)(6) introduced herself to the group, and initially appeared tense. As the sess1on proceeded, she relaxed somewhat,
::~ppearing to be listening and attentive and shared a bit of her experience toward the end of group.
SIGNATURES
Signature of Provider: (b)(6) Date of Signature: 7123/2007
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(b}(6)
ession: #16 (for this client)
bsent:
ontent of Session: Negative Self-Talk
ltrssign a number value to each category: 1=none; 2=rarely; 3=sometimes; 4=often; or N/A
It ~ceptance of Responsibility: 4
11- ~rsonal Disclosures: 4
~pathy tor others: 4
powledge & Understanding of Effective Parenting Strategies: n/a
I~ otivation for Change: 4
espectful attitude: 4
lc vera II Participation: 4
i
FECT: THERAPEUTIC CONCERNS:
beat X Incident of Re-abuse
arded Suicidality
sentful Increased Risk of Re-abuse
C lm X Hostile, Aggressive Behav1or
F ~strated Increased Depression
R ffective X Increased Stress
ln~ppropnate Other:
Flpt None X
A gry
S<d
A1 xious
C nfident
A gretful
0 her (state type)
C MMENTS or SUMMARY:
Tt s was (b}( 6 } fast group. She reported that she had learned a lot and was putting the lessons into action. She has
be an a very valuable group member with a multitude of thoughtful contributions.
~IGNATURES
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t AP Clinical Contact Note
ase Number 36618 Client Name:
Contact Date: 11/13/2007
(b)(6)
bollateral Contact:
~urn mary of Contact:
Group Note/Participation Form
!
ate: Nov. 13, 2007 Client's Name (b)(6) Case Manager: (b )(6)
~
ontent of Session: Progression of Violence.
ssign a number value to each category: 1=none; 2=rarely; 3=sometimes; 4=often: or N/A
cceptance of Responsibility: 4
ersonal Disclosures: 4
mpathy for others: 4
nowledge & Understanding of Effective Parenting Strategies: n/a
1\ otivation for Change 4
iespectful attitude: 4
verall Participation: 4
~
t an "X" tor those that apply:
FECT: THERAPEUTIC CONCERNS:
beat Incident of Re-abuse
arded Suicidality
~
sentful Increased Risk of Re-abuse
lm X Hostile, Aggressive Behavior
ustrated Increased Depression
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fl.ective X Increased Stress
I ppropnate Other:
F t None X
A gry
s d
AfiOUS
C nfident
R gretful
0 er (state type)
r, or SUMMARY:
M~AI=I\ITS
6
asked for support today as she reflected on whether she did everything she could have to help her marriage work.
(b)( )
HEr divorce will be final this week, and she shared that she believes her ex-husband has been involved in another DV
inc ident with a new girlfriend. The group offered her much support.
~ IGNATURES
S ~nature of Provider: (b)(6) Date of Signature: 11115/2007
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tAP Clinical Contact Note
c ase Number 36618 Client Name: (b)( 6)
~ollateral Contact:
ummary of Contact:
Group Note/Partictpation Form
~~MMFNTS or SUMMARY:
(b)(6) ~Vorked hard to grasp the tdea of being respectful and still effectively expressing anger. She is angry at her MC.
wr o seems more sympathetic to the financial stress on her ex-husband instead of her need for help (she says her estranged
hu band has promised for months to give her child support, but hasn't provided any support since they separated).
EIGNATURES
S ~nature of Provider: (b)(6) Date of Signature: 9/12/2007
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~AP Clinical Contact Note
¢ase Number 36618 Client Name: 6
(b)( )
·----~------
"ollateral Contact:
:;ummary of Contact:
~roup Note/Participation Form
9ate: July 31, 2007 Client's Name: (b)(6) Case Manager: (b)(6)
jE!;lssion # 3
~
sign a number value to each category: 1=none; 2=rarely; 3=sometimes; 4=often; or N/A
A ceptance of Responstbihty: 3
rsonal Disclosures: 3
R spectful attitude: 4
Oterall Participation: 4
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nfldent X
flegrettul X
O:OMMENTS or SUMMARY:
(b)(6) was very interactive in this sess1on. She gave several examples relating to specific effects of the domestic violence
9n her son
SIGNATURES
~ignature of Provider: (b)(6) IDate of Signature: 81212007
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I Collateral Contact:
I Summary of Contact:
· 18 October 20~7
TC from SM, b)( 6) He sa1d hA thought he had compl~te£( group.
TC to group facilitator (b)(6) She said that she and )(b/ thought SM has not demonstrated enough in the group to
recommend to close as resolved.
TC to SM. Informed htm he has to complete two more sessions and demonstrate that he has learned something in the group.
He agreed to attend two more sessions.
SIGNATURES
Signature of Provider: (b)(6) Date of Signature: 11/28/2007
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! Clinical Contact Note
(b)(6)
Case Number 37009 Client Name:
Contact Date: 8/29/2007
Time Spent: 2 !Type of Contact: In Person
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group IType of Session: Group
Session Notes:
Group Note/Participation Form
i~~~
nxious
onfrdent
egretful
HERAPEUTIC CONCERNS:
I cident of Re-abuse
I~ uicrdality
I creased Risk of Re·abuse
I~ ostile, Aggressive Behavior
I creased Depression
I creased Stress
ICOMMENTS or SUMMARY: SM was relatively quiet during group. SM seems to respond more when female therapist is in
r om. SM was able to orovrrlA <:nmo f~edback to other group members. but his thinkrng remains relatively rigid.
(b)(6)
IP an Status ,·.u
'·' ·
j i! ,)
< IGNATURES
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\Clinical Contact Note
(b)(6)
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l Case Number 37009 Client Name·
Contact Date: 8/15/2007
, Time Spent: 2 jType of Contact: In Person
Number of Individuals Seen: 0
Type of Counselin~ Group: Offender Group jType of Session: Group
Session Notes:
Group Note/Participalton Form
rustrated Reflective
rappropnate
lat
ngry
ad
nxious
onfident
egretful
HERAPEUTIC CONCERNS:
I cident of Re-abuse
'~ uicidality
I creased Risk of Re-abuse
1- ostile, Aggressive Behavior
r creased Depression
lr creased Stress
COMMENTS or SUMMARY: SM was able to provide some support and feedback to other group members dunng session.
S~ continues to place res~nsibilitv tm rl<>t<>ri,..,..,+'"'1 of relationship on CW.
(b)
-·
p an Status ..
· ,,:,•;,; ; : .. ';·;.: i'•.:•: ;".i; ':: :: ·.,.,,' ::.'.! ·:
A ~commended Referrals:
111 House FFSC:
F p
IExternal Military: !External Civilian: ITri..Care:
~ IGNATURES
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1 Type of Counseling Group: Offender Group
Session Notes:
Group Note/Participation Form
jType of Session: Group
1
Date: 08/8/07 Client's Name: (b)( 6) Case Manager:(b)(6)
Group Name: Cypress II Group Leader(s): TW & LH Session # (for this client):
Assign a # value to each category: 1=none; 2=rarely; 3:::sometimes; 4=often; or NIA
Acceptance of Responsibility: 1
Personal D1sclosures: 2
Empathy for others: 2
· Knowledge & Understanding of
Effect1ve Anger Management Strategies: 1
Motivation for Change: 1
Respectfulaltltude:3
Overall Participation: 3
Put an "X" for those that apply:
AFFECT:
Upbeat
Guarded
Resentful X
Calm
Frustrated Reflective
nappropnate
lat
f\ngry
~ad
.,_nxious
~onfident
~egretful
HERAPEUTIC CONCERNS:
ncident of Re-abuse
uicidality
lrcreased R1sk of Re-abuse
!"'We, Aggmsoive Behav•o•
creased Depression
creased Stress
OMMENTS or SUMMARY: SM continues to present as rigid in his thinking. SM continues to state that he is basically a
erfect" husband and father and that his wife is to blame for all of their relationship problems. SM was disrespectful to
f male facilitator bv suoaAstinn th"t "ho "" ~ "pole dance".
(b)(6)
iA ~ommended Referrals:
lr House FFSC:
F p
I
External Military: IExternal Civilian: ITri-Care:
, !GNATURES
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creased Stress
mments or Summary:
. attended and participated 1n today's session of the Khulam Group. He was quiet throughout the group but appeared to
y attention to the comments and statements made by other group members.
-·---·-· (b)(6) .
utuu!Jl'lotewartiCipatiOn Form
D te" 7/25/07 Client's Name: (b)( 6) Case Manager: (b)(6)
G oup Name: Khulani I Group Leader(s): - - (b)(6)
S~ss1ons Attended Absent: X Halfway pomt· 1-inal Sess1on·
C ntent of Group:
A ew facilitator began with the group today. Introductions were conducted with all group members sharing his/her
pr senttng problem and the need for Fam11y Advocacy serv1ces. A p1ece from SOS Basic Parentmg skills was v1ewed by the
g~rup and served as the basis for discussion for the class. Focus of group was to discuss positive parenting strategies and
ef ctive discipline. Th1s led to a discussion of different discipline techniques.
A ign a number value to each category: 1=none; 2:::rarely; 3=sometimes; 4=often; or NiA Acceptance of Responsibility: NA
P sonal Disclosures:
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1Put an "X" for those that apply:
AFFECT:
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Upbeat
Guarded
Resenlful
Calm
Frustrated Reflective
!inappropriate
Flat
Angry
Sad
Depressed
Anxious
Confident
Regretful
Therapeutic Concerns:
Incident of Re-abuse
Swcidality
Increased Risk of Re-abuse
Hostile, Aggressive Behavior
Increased Depress1on
ncreased Stress
t:;omments or Summary:
J::;lt. was absent. Case Manager notified.
!
(b){6)
~ecommended Referrals:
~-House
AP
FFSC: IExternal Military: IExternal Civilian: ITri-Care:
SIGNATURES
~ignature of Provider: (b)(6) I
Date of Signature: 816/2007
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1 Group Note/Particrpatron Form
(b)(6)
Session# 5
Acceptance Of Responsibility 2
Personal Disclosures 2
Empathy for child and/or others 2
Knowledge & Understanding of
Effective Anger Management Strategies 2
Motivation for Change 2
Insight & Self Awareness into
Behavior
~
f'espectful attitude 3
C>verall Partrcipation 2
IR ~commended Referrals:
lr House FFSC:
F p
I External Military: lExternal Civilian: ITri-Care:
JGNATURES
S gnature of Provider: (b)(6) j Date of Signature: 712312007
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Collateral Contact:
Summary of Contact: (b)( 6)
On 10/10/07, case presented at CRC for 90 day review, however, QA supervisor instructed CM to close the case
fince the SM has completed 25 sess1ons of his 52 week DV group. Case tnstead was presented as Closed as RESOLVED.
pn 10/10/07, TC to the SM a1 6
(b)( ) SM reported that he is still attending his court ordered tx and all is going well with
im and CW. CM explained that his case would be closed as resolved w1th FAP, but he would need to finish his 52 week
l roup in order to be in compliance with the court. SM related that he plans to finish and will bring in his certificate of
ompletion to FAP after he receives it.
SIGNATURES
Signature of Provider: (b)(6) Date of Signature: 10/11/2007
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•
•
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fAP Clinical Contact Note
. ~ase Number 38583 Client Name: C (b)(6)
~ollateral Contact:
· ~ummary of Contact:
On 8/15/07, TC from (b)( 6) SC will flu on getting the SM over to SARP after meeting with the DAPA. CM
onfirmed that the SM has been compliant and has provided CM with progress reports for his 52 week DV group in the
. ommun1ty. SC will contact CM with the results of the SARP evaluation.
SIGNATURES
(b)(6)
Signature of Provider Date of Signature: 8/15/2007
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ased on his self report of abusive behaviors, police report, court conviction and the preponderance of clinical information.
M 1s currently attending his 52 week OV group in the community and has completed 6/52 sessions. He will be referred to
ARP for an ETOH evaluation.
SIGNATURES
H-------------
lgnature of Provider (b)(6) Date of Signature: 7/16/2007
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~AP Clinical Contact Note
(b)(6)
¢ase Number 38583 Client Name:
(b)(6)
i "ontact Date: 7!212007 Clinical Provider:
ollateral Contact:
:~mmary of Contact:
n 7/2i07, OV with the SM. SM came in to drop off proof of enrollment paper work. SM reported that he is attending his
Qtoup and has completed 6 sessions. SM related that he pays $25.00 per session, but he plans to be consistent with his
~~ndance. SM related that he and his wife are getting along well. SM will keep CM informed if he has to go underway and
provide quarterly progress reports.
1
, SIGNATURES
1! ignature of Provider: (b)(6) Date of Signature: 7!212007
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.fAP Clinical Contact Note
¢ase Number 38583 Client Name: (b)(6)
·-
L (b)(6)
:pontact Date: 7/2/2007 Clinical Provider:
;~ollateral Contact:
!~mmary of Contact
I n 7!2107, TC to the SM a (b)(6) CM discussed the upcoming CRC. SM confirmed that he has been attending his 52
#eek DV group in the community at SO Center For Families. SM stated that he has completed 6/52 sessions. CM reminded
t e SM that he needs to bring in proof of enrollment as well a quarterly progress reports. SM related that he could drop off a
lppy of h1s enrollment this week. SM reported that there is no RO in place and he and CW are living together and doing well.
. piG NATURES
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Collateral Contact:
Summary of Contact:
CM called SM to see if he has attended 16 sessions of Court Ordered treatment yet, and he informed he has. SM will bring
in court document provig completion and case can be closed.
SIGNATURES
Signature of Provider: Date of Signature: 4115/2008
https://ffsmis.cnic.navy.mil/components/forms/PrintAllFonns.aspx 12/22/2010
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Administrative Note
Case Number 42311 Client Name: (b)( 6)
Collateral Contact
~ummary of Contact:
1Case presented lhts day to CRC for closure. SM has successfully completed 16 weeks of DV group in the community and
rovided documentation of attendance to CM. Case closed as resolved wl!h a risk ratmg of LOW. Closing letter drafted;
eriodtc CRC rev1ew and risk assessment update completed.
lis iH
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Collateral Contact:
Summary of Contact:
SM provided case manager with proof of attendance at 16 weeks of OV group in the community. Case to be presented at
~RC on June 4, 2008 for closure.
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' FAP Clinical Contact Note
, Case Number 45997 Client Name: (b)(6)
;
Contact Date: 4/24/2008 Clinical Provider: (b)(6)
Collateral Contact:
Summarv of Contact:
(b)(6)
just spoke with his Department Senior Chief. (b)(6) will provide you an update tomorrow. Unfortunately we are domg an
nspection today and he can not come over touuy.
JiR
(b)(6)
f-!IPR: (b)( 6)
piPR: (b)( 6 )
~SS DENVER (LPD 9)
·po AP 96663-1712
OTS: 619-545-0389
an Diego Pier Side: 619-556-4244
---Origmal Message-----
rom: (b)(6)
ent: l.tUI..;;JUUJ, ntJIII L"T, LUVO IU.I/ ArvJ
o: (b)(6)
Ubj8Ct: (b)(6)
hie!,
llhave not heard from (b)( 6) in some time. He was supposed to give me on a monthly basis, his attendance record from
1 e 52 week in the community. I have not seen or heard from him In about two months.
it lease tell that young gentleman that if I do not hear from h1m in one week I will be closing out his case as a "Treatment
IH:~ilure•. Thank you as always for your help
1\ 'R. (b)(6)
lt:p6-8316
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: ;;oliateral Contact:
IIJiummary of Contact:
1 1 !Had the follwing further commun1catton with (b)(6) today:
I·
(b)(6) Thank you; it's quite honorable for (b)(6) to participate in ftghting the f1res.
~~-~rioinal Mossanr>(b")(i:>)
tnt: TuASrl8v .Jt 1lv 01 ?OOA 11·~~'>
. (b)(6)
~bject: RE: Relaying "FOUO" Material
(b)(6) ts on Detachment right know helping out With fightmg the fires m Northern California As
9pon as he gets back I will touch base w1th him and set something up with you. Thanks again.
(b)(6)
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···~ ignature of Provider: (b)(6) Date of Signature: 7/1/2008
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ffAP Clinical Contact Note
(tase Number 46649 Client Name: (b)(6)
! (b)(6)
ontact Date: 7/1/2008 Clinical Provider:
1
ollateral Contact:
~ ummary of Contact:
! ~eceived tt1e following reply from (b)(6) re: status of SM's court ordered tx with this CM's reply:
(b)(6) (b)(6) since I didn't
Thanks very much for the update. I'm interested 1n meetmg w1th
rypve the opportunity mit1ally, as this case was transferred to me from another case manager and since I'd like to evaluate if
h s FAP case can be closed m the very near future. At this point, after the holiday would be a good t~rne to meet wtth him.
ranks very much.
--Original Message-----
om (b)(6)
ent· Mondflv .hmA :iO ~OOR 1R·14
·h (b)(6)
$ubject. RE Relaying "FOUO" Matenal
:i
(b)(6) , as of nght now (b)(6) has completed 21 weeks of the DV program with out missing a beat. Pretty close to
~ve way done and he is complymg with the co"rts ocdecs. As lac as the eval"at•on, he was g"en a soeenmg hem at ow
mmand months ago with our Command DAPA. After the screening and evaluation it was determined by the DAPA that it
d not need to go to level one treatment at Pomt Lorna. He is takmg this very seriously and is comm1tted to making this work.
an definitely keep you tnformed w1th all progress any time you ask (b)(6) fhank you for keepmg in contact.
(b)(6)
"
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(b)(6)
; p Case Manager
val Base San Diego
~mm 6 t 9-556-6438
N: 526-6438
. x:619-556-9678
"~or Official Use Only- Privacy Sensitive" Any misuses or unauthonzed disclosure may result 111 both c1vil and criminal
rt nalt1es
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, FAP Clinical Contact Note
(b)(6)
' Case Number 46649 Client Name:
Contact Date: 12/14/2007 Clinical Provider: (b)(6)
Collateral Contact:
Summary of Contact:
TC to SM to inform that this CM has been assigned to h1s case and to inquire about progress. SM stated that he has
ompleted 4 weeks of the 52 week DV program which was mandated by the San Diego Superior Court SM reports that there
1ave been no further incidents between he and wife. SM has this CM's contact information.
J., t !HE':;
Signature of Provider: (b)(6) Date of Signature: 12!14/2007
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i:;unical Contact Note
;ase Number 48961 Client Name: (b)(6)
p8SSIOn # 1
~cceptance Of Responsibility 1
::>ersonal Disclosures 1
rnpathy for chrld and/or others 1
nowledge & Understand1ng of
ffect1ve Anger Management Strategies 1
~ollvation for Change 1
nsight & Self Awareness 1nto
3ehavior
=lespectful attitude 1
)verall Participation 1
Collateral Contact:
Summary of Contact:
(b)(6)
just spoke w1th him last week actually, he has attended 6 sess1ons. He has a court date for review ot his progress on March
5th. At that time he will be turnmg in his progress report to me from DVRP and I will fax you a copy.
thank VOU.
(b)(6)
pOUTHWEST REGIONAL MAINTENANCE CENTER
amily Advocacy' Representative
CPOA Treasurer
~755 BRINSER ST., SUITE 1
pAN DIEGO, CA 92136
VvORK:619-556-2937
~ell (b)(6)
MAIL (b)(6)
----Ori(Hn81 ~-rm):'lnP.-----
rom: )( NAVST A San D1ego
pent: Tuesday1 Marct1 11. 2008 9 22
o (b)\6) SWRMC, C1 134
~c , (b)(6) 3WRMC
~Ub]eCt: l-AP
-1~,ave a review on(b)( 6) ·. Is there any way that you can tell me il he has been attending the 52 weeks court ordered
reatment and it so, how many sessions did he attend.
'/r
(b)(6)
(b)(6)
:::ase Manager
\Javy Region Southwest
i 9-556-2090
he mforma!ion transmitted is intended solely for the individual or entity to which 1t is addressed and may contam conftdent1al
nd/or priVIleged matenal. Any review, retransmission, d1ssem111atton or other use of or taking action m reliance upon this
nformalion by persons or entities other than the tntended recipient is prohibited. It you have rece1ved this email in error
lease contact the sender and delete the material from anv computer.
SIGNArURES
Signature of Provider: (b)(6)
Date of Signature: 3/31/2008
proup revrewed and discussed the video "Men's Work": presentation of VIOlence and men's ident1ty
~o rnd1cat1on or new reports of mc1dent involvmg: Chlldispouse abuse, threats/danger to self/others or substance abuse· No
~_vidence of thought or mood drsorder noted
Plan Status
ptagnostic Impression
Recommended Referrals:
n-House FFSC: IExternal Military: jExternal Civilian: jTri-Care:
Group reviewed and discussed a video and power pomt presentat1on of emotions Identifying and defenses against emot1ons
No ind1cat1on or new reports of incidents involv1ng child/spouse abuse. threats/danger to self/others or substance abuse, No
ev1dence of thought or mood d1sorder noted
Plan Status
Diagnostic Impression
Recommended Referrals:
In-House FFSC: I External Military: I External Civilian: ITri-Care:
piagnostic Impression
~ecommended Referrals:
n-House FFSC: IExternal Military: IExternal Civilian: ITri-Care:
fSroup revtewed and discussed Rational Emotive Therapy techniques tn managmg thoughts and feelings
No indication or new reports of inctdents involvtng. childispouse abuse. threatsidanger to self/others or substance abuse~ No
vtdence of thought or mood dtsorder noted
Plan Status
piagnostic Impression
~ecommended Referrals:
r-House FFSC: !External Military: !External Civilian: ITri-Care:
>Jo mdtcatiOn of cllntcal nsk tncluding child/spouse abuse. threats/danger to self/others. and substance abuse, No indication
f suicidal or homtcidal idea !ton or thought or mood disorder
;,lan Status
)iagnostic Impression
~ecommended Referrals:
n-House FFSC: IExternal Military: !External Civilian: ITri-Care:
Group viewed and drscussed video "Why Am I So Angry" and were asked to rdentify w/ various scenarios
No indicatron or new reports of incidents involving child/spouse abuse, threats/danger to self/others or substance abuse, No
evidence of thought or mood disorder noted.
Plan Status
Diagnostic Impression
Recommended Referrals:
In-House FFSC: I External Military: I External Civilian: ITri-Care:
No mdication of new reports of mcidents involving child/spouse abuse. threats/danger to self/others or substance abuse: No
evidence of thought or mood disorder noted.
Plan Status
Diagnostic Impression
~ecommended Referrals:
n-House FFSC: !External Military: IExternal Civilian: jTri-Care:
Collateral Contact:
Summary of Contact:
The SM asked this case manager to wnte a letter for h1m to present to the LA Court so that he could rece1ve credit for the
DV sess1ons he attended in our Men's Group They also wanted to know the format of the FFSC men's offender group Th1s
counselor faxed the letter to the SM the same day
(b)(6}
Signature of Provider Date of Signature: 1113/2008
~-------------'----------------------'
Group rev1ewed men's group onentation w1th a power point presentation followed by an overview of effective sk1lls 1n
managing behav1or.
No mdication or new reports of mc1dents involving. child/spouse abuse. threats/danger to self/others or substance abuse. No
evidence of thought or mood disorder noted.
Plan Status
Diagnostic Impression
Recommended Referrals:
In-House FFSC: IExternal Military: IExternal Civilian: ITri-Care:
!G lA Jl~
(b)(6)
Signature of Provider: j Date of Signature: 1/1112008
\lo indicatron or new reports of incrdents involving: child/spouse abuse, threats/danger to self/others or substance abuse; No
::vident of thought or mood drsorder noted.
Pian Status
Diagnostic Impression
~ecommended Referrals:
n-House FFSC: !External Military: IExternal Civilian: jTri-Care:
Si· . i/\ :ES
I t - - - - - - - - - - · · -......
$ignature of Provider:
~- .
(b)(6) IDate of Signature: 1/712008
Diagnostic Impression
Recommended Referrals:
In-House FFSC: IExternal Military: IExternal Civilian: jTri-Care:
SM's first group. He Introduced h1mself briefly without giving details about his reason for being in the group No 1nd1cation of
climcal nsk Including. child/spouse abuse. threatsfdanger to self/others. and substance abuse. thought or mood disorder
Plan Status
Diagnostic Impression
Recommended Referrals:
n-House FFSC: jExternal Military: jExternal Civilian: jTri-Care:
l-----------------········-···------.....----------------------------------4
Signature of Provider: (b)(G) IDate of Signature: 12/13/2007
!Group v1ewed and revtewed video presentation by Gottman on self-soothmg. D1scuss1on followmg regarding "time-outs"
No ind1catron or new reports of tnctdents involvtng. child/spouse abuse. threats/danger to self/others or substance abuse. No
evrdence of thought or mood disorder noted
Plan Status
Diagnostic Impression
Recommended Referrals:
n-House FFSC: IExternal Military: IExternal Civilian: jTri-Care:
li GSSIOn #
. cceptance Of Responsibility 3
If ersonal D1sclosures 3
If mpathy for child and/or others 3
If nowledge & Understandmg of
IE ffective Anger Management Strategies 3
1otiva!lon for Change 4
I ~sight & Self Awareness into
ehav1or
espectful attitude 3
Overall Participation 3
ian Status
Diagnostic Impression
i(ecommended Referrals:
n-House FFSC: !External Military: IExternal Civilian: ITri-Care:
SIGNATURES
I ttps://ffsm is.cn ic. navy. m i I/components/ fom1s/Prin tAilF om1s. aspx 12/22/2010
( linical Contact Note
(b)(6)
( ase Number 50539 Client Name:
!( on tact Date: 9/11/2008
ime Spent: 1.5 \Type of Contact: In Person
umber of Individuals Seen: 1
ype of Counseling Group: Offender Group \Type of Session: Group
ession Notes:
sroup Note/Participation Form
~ession # 2
1\cceptance Of Responsibility 3
::Jersonal Disclosures 3
~mpathy tor child and/or others 3
f<nowledge & Understanding of
..._ftective Anger Management Strategies 3
rv1otivation for Change 4
nsight & Self Awareness 111\o
~ehavior
~
Respectful attitude 3
Overall Participation 3
Plan Status
Diagnostic Impression
Recommended Referrals:
In-House FFSC: IExternal Military: \External Civilian: \Tri-Care:
SIGNATURES
httns://ffsmis.cnic.navy.milicomponents/forms/PrintAllForms.aspx 12/22/2010
( linical Contact Note
(b)(6)
( ase Number 50539 Client Name: ---
I C on tact Date: 8/27/2008
ime Spent: 1.5 IType of Contact: In Person
I r umber of Individuals Seen: 1
ype of Counseling Group: Offender Group \Type of Session: Group
1
~ ession Notes:
IC roup Note/PartiCipation Form
(b)(6) Case Manager: (b)(6)
' [ate: 8/27/08 Client's NamE
I~ ession # 2
/- ceptance Of Responsibility 3
iF ~rsonal Disclosures 3
1Ernpathy for child and/or others 3
.I< rowledge & Understanding of
: E~ecl1ve Anger Management Strategies 3
.1\i otivation for Change 4
Jr sight & Self Awareness 111to
· B~havior
3
Respectful attitude 3
C verall Participation 3
~ ~arded Suicidahty
pbeat Incident of Re-abuse
p ~n Status
D [agnostic Impression
R commended Referrals:
In House FFSC: IExternal Military: IExternal Civilian: ITri-Care:
t !GNATURES
S gnature of Provider (b)(6) IDate of Signature: 8/28/2008
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.1 lflll. r\..11 J.VJIJl;:)
S ssion # 1
lA ceptance Of Responsrbility 3
Personal Disclosures 3
E[npathy for child and/or others 3
IK rowledge & Understanding of
E~ectrve Anger Management Strategies 3
ltv jotJV<Jtion for Change 4
lr sight & Self Awareness into
IB ~havror
3
i R~spectful attitude 3
~erall Part>cipatioo 3
. FECT THERAPEUTIC CONCERNS
beat Incident of Re·abuse
uarded Surcrdality
'~ ~sentful Increased Risk of Re-abuse
·C81m x Hostile, Aggressive Behavror
F ustrated Increased Depression
! F ~flec!ive Increased Stress
lr appropriate Other
Fat None
p ngry
IS j;ld
I~
rxious
pnfident
I~ ther
~gretful
IF an Status
I C!agnostic Impression
IF!ecommended Referrals:
h -House FFSC: IExternal Military: IExternal Civilian: jTri-Care:
~IGr'IIATURES
~ ignature of Provider (b)(6) J Date of Signature: 4/2/2008
p.PPENDAGE NOTE
~mber !Appendage Note !Provider's Name !Date
I I I I
(b)(6)
111 !Date of contact should be 8/27/08 112/9/2008 3:32:00 PM
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J->rnn /\ ll J• 0 rm s
(b)(6)
~ontact Date: 2i1/2008 Clinical Provider
l Thank You
(b)(6)
&>UTHWEST REGIONAL MAINTENANCE CENTER
Fprnily Advocacy Representative
FCPOA Fundrwsing Coordinator
3f55 BRINSER ST , SUITE 1
Sl'\N DIEGO, CA 92136
~VORK:Gi 9-556-2937
Cbl! (b)(6)
E~1AIL: \b)(b)
.. !..onoinal Messaae-----
Fforn: (b)( 6 l CIV Family Advocacy Center ,Family Advocacy Center
Spnt: Wednosdav. Ann I :::>s. :::>007 1· iQ PM
T~: (b)(6)
SirtJjeC<: Hl::: (b)(6)
1
(b )(6)
you been ablt'l to determine how many DVRP sess1ons the SM has attended? I need to turn 1n my 90-day review form
Thanks,
(b)(6)
C:tlse ~-llanager
F;~mily Advocacy Center
31l35 Dolphin Alley, Bldg 261
S4n D1ego, CA 92136-5185
(6~ 9) 556-8827
F4X (619) 556-9473
(b)(6)
i\APi':<:::<!1o'>-- ---
b)(6)
Fridav. Aoril 20. 2007 11:20
(b)(6) Fam1ly Advocacy Center ,Fam1ly Advocacy Center
(b)(6)
wanted to update you that based on the 11lformat1on we received from you and MM3 chief we are isssuing a 30 day
and plan to reJssue a 7 day MPO at the end of 30 days to carry SM out to his court date. If you could clanfy some
for me: Was there more than one Incident or did all th1s happen on one day? If so what were the days of the
Yo11
(b)(6)
/SqUTHWEST REGIONAL MAINTENANCE CENTER
• ···Orioinal Messaoe·-··
rom: (b)(6) CIV Family Advocacy Center ,Family Advocacy Center
ant: Thursday, April i9i 2007 3:13PM
o: (b)(61
ub]ect (b)(6)
i (b)(6)
I need some help from you regarding the above SM. Can you get in touch with him and find out how many DVRP classes he
as completed? The court sentenced him to 52 weekly sessions. I'm doing a 90-day review of his case and I need to know
xactly what he has completed. I also need to know if he completed an evaluation at SARP. Can you find out this for me
Iso? Thank$ {p)(c,)
(b)(6)
ase Manager
mail: (b)(6)
SIGNATURES
~ignature of Provider: (b)(6) IDate of Signature: 5/10/2007
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for 90-day rev1ew. SM states he has completed 11/52 DVRP sessions in the communtly. He reports he IS learn1n9
sess1ons. He 1s back living al home and 11e and CW are gettin9 along better.
lsessron II 4
~d1!ional
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{b)(6)
External Civilian:
(b)(6)
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SM as he stopped 1n on his way to begin group Khulani He requested a court letter to request the court consider FAP
options. Let1er written. SM took Monday off to deal with the court
signed a ROO for the Vista Superior court.
June 2007
by SM. prior to go1ng into groups. He provided a court document slating the court will accept FAP treatment. He
a letter to take to court on 10 July.
(b)(6)
Date of Signature: 11/28/2007
~eSS!On #2
Contact Note
(b)(6)
Session Notes:
Group Note/Participation Form
Date: 6/20/0I Client's ~Jame: (b)( 6 ) Case Manager (b)(6)
Group Name: Khulan1 I Group Leader(s): (b)(6)
Sessions Attended: 2 Absent: Halfway po1nr: r1na1 ::;ess1on:
"icontont of Group:
;roday's group members complete\J a family of origin worksheet and participated in a group discussion regarding the 1mpact
~FOO has on current parenting.
;1\sSI[Jn a number value to each category: 1=none; 2=rarely; 3o:somet!mes; 4=oft<~n; or N!A Acceptance of Responsibility: 1
jPersonal D1sclosures: 3
'Empathy lor others 2
~nowledge & Understanding of
iEIJective Parent1ng Strategies: na
lrvlotivation for Change: 2
!Hespectful attitude: 4
lpverall PariicipatJOn: 3
'F'ut an "X" for those that apply:
!AFFECT:
IWpbeat
punrded X
1
Resentful
Calm
frustrated
Aoflectr.;e
rbapproprwto
ft'lat
;\lngry
Sad
Qopressed
4,nxious
C~onf1dcnt
liegretful
~11orapoutic Concerns:
lrllc!dent of Re-abuse
~UIC!da/ity
lr~creased Risk of Re-abuso
Hosl!lo, Aggross1vo Bohav1or
lrlcroasod Depression
lrlcreased Stress
clomments or Summary:
qt. continues to take minimal responsibility for refornng mcident and IS blaming toward wife. Due to time constraint client d1d
n~t sllare FOO worksheet however will share next session Client appeared to be actively listening to other group members.
(b)(6)
(b)(6) 6/25/2007
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Contact Note
(b)(6)
CONCEFiNS:
Aggress1ve Behavior
Depression
Stress
or SUMMARY: SM's first sess1on. SM placed blame for refernng inc1dent all on CW SM appoGrs to be rigid in
(b)(6)
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~AP Clinical Contact Note
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ase Number 59499 Client Name: (b)(e)
(b)(6)
ntact Date: 5/14/2008 Clinical Provider:
- - - - - - - - - - - - - - - - + - - - · - - - - - - - - · - · - - · - - - - - . -·
ime Spent: 0.25 Type of Contact:
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Contact:
Summary of Contact:
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On 5/14/08, transfer-in case was presented to CRC. It was recommended to close the case
+s resolved since the SM has completed 34 out of 52 group sessions of his court ordered DV
roup.
(b)(6)
Date of Signature: 5/19/2008
.mil/components/forms/PrintAIIForms.aspx 1/7/2011
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(b)(6)
ase Number 59499 Client Name:
. + - - - - - - - - - - - - - - - - - - . - - - - - - - - - - - - - - - - - - - - ----,
(b)(6)
Contact Date: 312612008 Clinical Provider:
Type of Contact: In Person
ollateral Contact:
$ummary of Contact:
lon 3/26/08, OV with the SM. He came in to discuss his transfer-in case. The Privacy Act
vfas discussed and signed. FAP was discussed. SM reported that he arrived in San Diego a
ftw weeks ago. His CW is in Sacramento, CA with his son. SM reported that he will be filing
t~e paper work for a divorce. SM gave a brief overview of the incident. CM confirmed that his
cf:!se record from 29 Palms had been received and reviewed. SM reported that he has
Ef'ljoyed his DV group and has completed 34/52 sessions. SM was provided with information
rtgarding certified DV groups in San Diego. CM informed him that he would also need to
ptovide CM with an enrollment report after he has decided on an agency. CM also informed
t'e SM that he would need to provide CM with a quarterly progress report. SM related that he
hBs made some friends in the San Diego area. He goes to the gym to lift weights when he
f~els stressed. SM denied Sl and HI. SM reported no current issues with ETOH. SM informed
QM that he does not contact his CW since she has a new boyfriend.
(b)(6)
Signature of Provider: Date of Signature: 3/26/2008
.mii!componentstforms/PrintAl!Forms.aspx 1/7/2011
Page 3 of 12
Collateral Contact:
Summary of Contact:
18 December 2008
M for SM to prov1de documentation.
January 2009
037- SM@ (b)(6) to provide documentation of DVRP enrollment
M had provided a document in late Dec 08 confirming that he had enrolled in a three hour anger management class at San
Jiego Continuing Education starting 20 October 08.
SIGNATURES
; ~ignature of Provider: (b )(6) Date of Signature: 1/5/2009
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Collateral Contact:
Summary of Contact:
16 October 2008
trc to SM. He said that he is still looking for a 26 week group.
t7 November 2008
(b)(6)
1otifled me that called her asking why I recommended a 52 week group for SM.
(b)(6) notified me that ;:>M found a 26 week and is enrolled and he should be contacting me.
9 November 2008
925 • TC to SM to obtain his proof of enrollment. He said he had it and would bring it by. He said he would call before
hawing up .
. SIGNATURES
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· Collateral Contact:
·. Summary of Contact:
, 6 October 2008
M for SM@ (b)(6} to determine if he has been sentenced to DVRP.
h"C from SM. He reported that the Judge told him that he needed to complete a 26 week DV class and if he can't find one
hen he needs to take a 52 week class. He said he would sign up and notify when he does.
~ October 2008
015- LM for (b}(6} and (b}(6}
400 - Case to CRC
CMD present. (b}(6} and his assistant
ncident substantiated with SM as offender of DV and CW victim.
reatment rec: SM enroll/complete 52 week DV tx program.
Letter in process
530 - TC to SM notifying him of CRC results and his need to provide certificate of enrollment
S signed up for 12/17
t! SIGNATURES
ignature of Provider: (b)(6} Date of Signature: 10/9/2008
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~dministrative Note
~ase Number 73548 Client Name: (b)(6)
!!Contact Date:
Appointment Administration:
!~/20/2009
~rovider's Administrative Notes:
arne: (b)( 6 l Status update per TC with (b)(6) ADM is currently
(b )(6)
TAD to the Wing, is compliant to treatment as ordered by Court. SM is
retiring in August 2009 and will therefore not face Courts Martial. He is
compliant to mandated 52-week DV treatment in community and individual
therapy. He is compliant with RO.
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I=AP Clinical Contact Note
(b)(6)
t:ase Number 74016 Client Name:
-
Contact Date: 2/19/2010 (b)(6)
Clinical Provider:
-
Time Spent: 0.25 Type of Contact: Phone
Collateral Contact:
Summary of Contact:
PC received from client asking whether he can do 26 of the 52 DRVP classes here at FAP to
ave money. Although he in no longer active duty, he reports he is still a beneficiary due to his
rvife also being in the military. He reported he has not obtained spouse ID yet. Requested he
peak with court to see if they will approve it prior and to provide proof that he is still a
eneficiary through her (still married, spouse 10, etc.) If court approves, CM will inquire into
ow to manage case since case has been closed and if tx at FAP is still an option.
SIGNATURES
Signature of Provider: (b)(6) Date of Signature: 2/19/2010
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httfs:i/ffsm is. en ic.navy. mi IIcomponents/IOnn s/Pri ntAII Fonns.as px 1/712011
=AP Clinical Contact Note
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•l:ase Number 74016 Client Name: (bl< l
-
(b)(6)
Contact Date: 9/30/2009 Clinical Provider: .
-
irime Spent: 0.25 Type of Contact: Email
~ollateralContact: GOVERNMENT AGENCY/ORGANIZATION
~ummary of Contact:
·Barbara,
~VM has been separated from naval Service.
W/R
(b)(6)
~FAR
ss BOXER
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(b)( ) (ENG) - SVM involved in DV incident 24NOV08 and arrested for DV against
1~ pause. CRC met 21JAN08 and determined this case to be substantiated. CRC recommends
I<= ttendance at the court ordered 52 week treatment program. SVM is responsible for providing
1c ocumentation of his enrollment and completion. SVM may wish to request that the court
lc llow SVM to attend a FAP educational session and 16 week men's group sessions at FAP in
I ~u of all or part of 52 week program.
SIGNATUR :s
;ignature of Provider: (b)(6) Date of Signature: 9/30/2009
h~ps:!ltlSmis.cni
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K~ollateral Contact:
~ ummary of Contact:
: ~et with ADM to check in with h1m regarding his treatment and to get letter from his current 52 week group facilitator to
srow that he has been attending sessions. ADM gave me letter to show that he has completed 25 sessions and that he will
fi~ish his 26th session tonight Let client know that when he completes his 26th session to fax me signed letter from his group
f< cilitator and that I could sign his case up for CRC at that time so that the case can be closed. Check in with ADM on how
h s classes t1ave been gomg and ADM state that he is teaming a lot more about DV and all the different types of abusive
b~hav1ors that are considered DV (verbal abuse, emotional abuse, threatening behaviors .. ) ADM stated that he is working on
itrf{ing to focus on himself and be a better person for himself in the future. ADM stated that he has not had any contact with
:11VJ and that he 1s continumg with the divorce process at this time. ADM stated that she has been back in California the past
·~ ree months, but there is still a civilian restraining order so ADM stated that he makes sure not to be anywhere near CW
.f;
~ ignature of Provider: (b)(6) Date of Signature: 6/9/2010
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I ollateral Contact:
~ ummary of Contact:
C with ADM letting me know he would be coming by Wed at 1000 to drop off his paperwork to show group attendance and
lc check in with me regarding his treatment update at that time .
. !·
! ignature of Provider: (b)(6) Date of Signature: 6t7/201 0
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~ ollateral Contact:
! ummary of Contact:
1 i C to ADM to check in w1th him.on his current treatment. ADM stated that he has completed 24 weeks out m the commumty
1a this time and will give me a copy of the form next week from his group leader to prove his attendance. Let ADM know that I
jv. ould be able to close case for h1m here after he completes 26 weeks.
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(b)(6)
, ~ase Number 99118 Client Name:
(b)(6)
:ontact Date: 3/10/2010 Clinical Provider:
:ollateral Contact:
:>ummary of Contact:
TC to ADM to check in with h1m on h1s current treatment progress and contact with his wife at this t1me. ADM stated that he
as completed 13 DV classes wrth no absences and will have completed two more by Wed of next week when 90 day CRC
t3view rs for hrs case. ADM stated that he just had court on 26 of last month and was told he is making good progress in his
t eatment. ADM stated that he just filed h1s divorce papers and has had no contact with CW since 25th of Jan and that she IS
· urrently out of the country visrting family 1n the Philipptnes for the next several months. ADM stated that he would drop off
apers show1ng that he has been attending groups on Wed 17 March around 1Oam.
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! : ignature of Provider: Date of Signature: 1/8/2010
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I ummary of Contact:
· -c to ADM letting him know what the results of the CRC were and the recommended treatment plan ADM stated that he
has already started the 52 week DV treatment groups that he was court ordered to attend. Let ADM know his options of
c mpleting 26 weeks on groups through the FAP program and than finishmg the rest of his 52 weeks out in the community or
j} st domg all his groups out 1n the communtty. ADM stated that 1t would be better for h1m to JUSt do the 52 weeks out in the
q )mrnunity. Let ADM know that I would need proof of attendance and the amount of classes he has completed every 90 days
11 ~d that we would close the case here after he has completed 26 sessions.
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~ ignature of Provider: (b)(6) Date of Signature: 1;7!2010
Collateral Contact:
~------------------------------------------------------------------------------------
Summary of Contact:
TC from ADH to this CM checkmg back in that he was told by the courts that he could not take the 26 week DV class here
and v.,rould be starting 52 week DV classes out in the community .
. ~----------~------------------------~------------------------------------~
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Collateral Contact:
' Summary of Contact:
TC to ADH to let h1m know that I looked 1nto gett1ng h1m into the 26 week DV groups that he can start here voluntarily before
his CRC review date as requested by h1m. Let cl1ent know th1s CM would get back to him to let him know if any spots are
currently open Jn the groups and what day t1e would need to attend if a spot did open up .
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Collateral Contact:
Summary of Contact:
CM spoke with the client regarding her progress on the CRC recommendations. Client has completed 35/52 weeks of her
DV counseling~ Client sa1d she goes to court on Thursday. 02 SEPT 2010 for custody of her daughter. Client reported sl1e 1s
"doing good, just a little sick~'' Client plans to bring CM a progress report 1n the next week, since she will request one for the
courts as well. Client asked if she can attend parenting class at FFSC. CM supported that and said she will call her back and
tell her when she can start.
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Client reported her ex-boytnend (b)(6) made a false allegat1on of child abuse (neglect) to CPS. Ghent said (b)(6)
claimed she was leaving the baby unattended and that she does not feed her.'' Client said CPS went to her house yesterday
but she was m Flonda, so obvtously CPS could not assess the baby. Client said CPS mterv1ewed her day care provider who
supported client in saying the allegations were false. Client reported CPS Will have to transfer the case to Florida if they want
to investigate since that is where her baby will reside, but if they do she does not intend to tell them her parents address.
(b)(6)
Contact Name:
https://ffsmis.cnic.navy.mil/components/forms/PnntAIIForrns.aspx 12/13/2010
rage L 01 1 r
Cpllateral Contact:
S~mmary of Contact:
• ---Ori01nal Messaoe-----
Frpm (b)( 6 ) NAVBASE San Diego, N9
SEnt: Tuesday, December 14,2010 10:24
T< (b)(6)
s bJect: rAP
(b)(6)
Trnk you for getting back to me to update me on your current treatment. For the FAP program you only need to complete 26
cl sses before I can close your case and I know out in the commumty it is 52. If you can let me know how many you have
co.· pleted in the 4 1/2 months that would be great The only other requirement is that I get a copy from your counselor when
yo fintsh the 26 classes to confirm how many you attended, but you can do that when you return. Thanks
\II
(b)(6)
H1~t &1-amtly Support Counseling Services
NTal Base San Diego
---fOriatnal Messaae-----
Fr m: (b)(6)
~a t -, ue:;uav, uecernoer(6)(i3)LU1 u l:J: 1:1
(b)(6)
(b)(6)
Supject. Update
M~ classes have been put on hold for my time on deployment. I wtll be resuming my classes as soon as I get back. lm around
thE 4 to 4 1/2 month marl<.. My counsler and the Judge have copies of my orders and know of my situatton. If there is any
ott!er questions please contact me at (b)(6) I would gladly answer them for you. Thank you for your time.
S GNATURES
Si ~nature of Provider: (b)(6) _joate of Signature: 12/14/2010
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) dministrative Note
{b){6)
( ase Number 108326 Client Name:
( ontact Date: 12/3/201 0 Appointment Administration:
-~ rovider's Name: (b)( 6)
{b){6) Administrative Notes:
ADM was transferred to the (b )(6) and is now deployed for 6-7 months so will be
continuing treatment when rmurns.
J,dministrative Note
Case Number 108326 Client Name: (b)(6)
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Administrative Note
C~se Number 108326 Client Name: (b)( 6)
s.cnic.navy.mil/components/formsiPrintAliFom1s.aspx 1?/?1!7()1()
clinical Contact Note
c ~se Number 108326 Client Name: (b)(6)
D i<lgnostic Impression
R commended Referrals:
In House FFSC: IExternal Military: IExternal Civilian: jTri-Care:
IGNATURES
S gnature of Provider: (b)(6) Date of Signature: 8/26/2010
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Collateral Contact:
~ummary of Contact:
This CM met with ADM to check in with him on status of him being separated from the Navy. ADM stated that he was told
e would be out of the Navy 6 June 2010 as general discharge. ADM stated that he was told he was being separated due to
t e CIVilian charge of battery after his second incident of DV at h1s court hearing on 21 May 2010. ADM stated that his XO is
ow try1ng to keep him in the Navy, but ADM stated that he feels that he was not supported by his command in the beginning
nd now just wants to get out. ADM stated that he started his 52 week DV groups last night out in the community and stated
t at he is also starting an anger management class and will be starting individual counseling for himself. This CM requested
t at ADM give my a copy to show that he has started his groups out in the community. ADM stated that he would FAX me a
1c ppy of the informat1on next week. Let ADM know that if he gets me a copy of the classes he wlll be continuing out in the
1c pmmunity I will be able to close his case as treatment completed due to him adequately participating in his recommended
ltr~atment while he could during his time here and continuing out 111 the community. This CM highly recommended that ADM
a so continue his individual counseling to gain support during this time. Talked to ADM about his plans for the future and his
s pport system. ADM stated that he is currently living with his mom and she has been very supportive and stated that a
c uple friends have a few JOb options lined up for him for when he gets out of the Navy. ADM stated that he is feeling better
npw that he has a plan and knows what is going to happen. ADM denied any current Sl.
3!GNATURES
~ ignature of Provider: (b)(6) Date of Signature: 5/26/2010
http :1/ffsm is. c n i c .navy. m i l!components/ forms/PrintA l!F orm s.aspx 12!22/20 10
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(b)(6)
(b)(6)
Date: 10/30!2007 Clinical Provider:
Col!ateral Contact
Summary of Contact:
Contact with f'..DF (b)( 6) regarding status of hor treatment at DVRP. RequestecJ documentatiOn verify1ng how many
(b)(6)
Note
(b)(6)
(b)(6)
Clinical Provider:
of Contact: Phone
of Signature: 2/8/2008
Contact
(b)(6)
(b)(6)
Contact
(b)(6)
Case Number 14721 Client Name
(b)(6)
Contact Date: 5/7/2007 Provider:
Time 0.25
(b)(6)
"-''jU I li:l"bl
FAP Request
very busv Wo'w3 boon out to sea w1th no port call for a long tune and everyone is gell1ng a little
couped up. as (b)( 6 ) she's avoiding rne l1ke the plague. I haven't been able to get 1t from her. I will try
hEn chnin of command on her aga1n and see if that helps. She is gett1ng out rn 1 month so I think she IS just try~mg
out and disappoar
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(b)(6)
(b)(6)
(b)(6)
, , .uo" ,,_,,d,., I...... _...,, ~u 1 .:-t:.::b t-'f\/1
(b)(6)
I- AP RL,QUEJS!
I wanted to let you know that I will be leaving rny pos1t1on at FAP and taking a new JOb at
(b)(G)
CFI\F-l as SM traditionally does not return CM's calls CFAR states thnt he spoke to SM a lew weeks ago and states
the couple are separated.
(b)(6)
(b)(6)
of Contact:
USS NIMITZ IS deployed and no Information has been recerved lrorn CFAR The followin9 email was sent again to
11 of DVRP sessions attended
1\!in<:'•V"lnr.
(b)(6)
~vv: uv classes
undenvay IS going 1Nell This 1S a follow-up to an emi:lil sene! 111 Marcil. Perhaps I can close tllis caso on (b)(6)
attended 16 court mandated DVRF' classes
Messaoe--··--
(b)(6)
2007 11'49
uv classes
can provido documentalion of 16 or more attendances at her court mandated DVRP, then I can close hc•r cnso
.. provrding thoro is no further issuo of DV. Can you please tlolp me get this rnfo.
(b)(6)
tvicssaoc:----~~
{b)(6)
''"JI''uav, uccemnm21, 20066.13
(b)(6)
(b)(6)
fviossnoo
(b)(6)
VVodnesday, December 20, 2006 11:48 PhA
(b)(6)
t.Jnon to ovmy class oxcopt the onos I've mrssed duo to bein(l undr,:rwny Th1s coming Wednosc)ay 1can get you a report
ilw class il!ld brlllp 1110 you
(b)(6)
(b)(6)
Contact Date; 12/2l/2006 Clinical Provider:
Collateral Contact:
Sununary of Contact:
EM/\IL FlESF'ONSE FROM CFAR
(b)(6)
MSC USN
(b)(6)
Phono
(b)(6)
(b)(6)
Provider.
Summary of Contact:
Tic to fl.DF She reports that she goes every Wed cven1ng frorn 4-6PM to hor DVnP with (b)( 6 ) She and
cont1nue to Jive together and she reports t111ngs am fino and that they can tnlk better now tllan beforo. She reports that
is not attendrng AA and that it was not a part of t1or cow1 tx plan. She states that she does not dnnk. !)()wever. t'\DF also
that she sees her probatron officer on a regular basrs.
Note
1472 i Client Name: (b)(6)
(b)(6)
In Person
probatJOn/30 IHs vltry cornrnunity servrce/approx S800 in court tees and lrnes/Good conduct order re: spouseilndrvidual
substance ilbuse counseling/attend f\A!abstarn from alcohol/attend anger rngm!/complete 52 week DVRP!cJo not reside
vrctirn unless approved by t11eraprst or victim's therapist
has sioned up lor 52 week program. She requests marital counseling and was 3clvrsed thai FFSC can provide alter she
makes good offor1 at l1er DVRP and safety rs not an issuo.
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Note
(b)(6)
(b)(6)
Provider:
(b)(6) 6/7/2006
n Contact Note
(b)(6)
Number 14721 Client Name:
13/2006 Clinical Provider:
of Contact: Phone
Summary of Contact:
1/c to CMC on 4/11 and 4/13 ro: MPO and ADF's release from Las Col1rws Detent1on Facility
CM to s,;t up an interview.
oday, called aQain aftor learn1ng that ADF was rnloased CMC statos that "ho entered a plea of not guilty, was prov1dod a
defender ami w111 return to court on Apnl 18 and a prelim1nary heanng IS set for the 23rd 111 order to set the trial date
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ltAP Clinical Contact Note
4ase Number 50539 Client Name: (b)(6)
----
tontact Date: 1/28/2010 Clinical Provider: (b)(6)
i f-OIIateral Contact:
ummarv of Contact:
(b)(6)
j
(b)(6) was dJschar~ed from the Navy around the time that I was
~'ng oumO'ec w'lh (b)(6 baok In Septembec. I am ha,;ng my Admlh
partment research his actual discharge date, but I can assure you that he
as not excused from attending any class sessions while he was attached to
e ship. ·
polog1ze for not closing the loop on him and his FAP case.
\
(b)(6) I
i ~IGNATURES
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t ollateral Contact:
Summarv of Contact:
(b)(6)
; wnting to follow up re (b)( 6 ) who was substantiated for DV and required to attend a DV Men's Group at FAP.
• was deployed for some time last year and returned and attended a group on 9/9/09 and 10/14/09, but has not attended
~ce He"" aiw nol pco,ided any w'illen e<eo" from lhe command to' the othe' dal" ml,ed in Sept 09, m ''"" ·
/14/09. Can you please let me know his status and if any of these absences are excused and when we can expect htm
ck in group. Thank you.
(b)(6)
l;. ensed Marriage and Family Therapist/Clinician
II\ avy Fleet and Family Support Counseling Center
3 35 Dolphin Alley, Bldg 261
Is ::m Diego, CA 92136-5185
!":'PMM: (619) 556-8315 DSN: 526-8315 FAX: (619) 556-9678
"t or Official Use Only- Privacy Sensitive" Any misuses or unauthorized disclosure may result in both civil and criminal
~~nalties.
'
'piGNATURES
1 ignature of Provider (b)(6)
Date of Signature: 1/2812010
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glinical Contact Note
(b)(6)
Case Number 50539 Client Name:
ontact Date: 10/14/2009
T me Spent: 1 .5 !Type of Contact: In Person
·I
ll)ii-Jmber of Individuals Seen: 1
!Tvpe of Counseling Group: Offender Group !Type of Session: Group
· S~ssion Notes:
Croup Note/Participation Form
IS~ssion # 9
ICpntent of Group: Coping with Stress
( =none; 2=rarely; 3=sometimes; 4=often; 5=very often)
·Pr;ceptance Of Responsibility 3
F ersonal Disclosures 4
Empathy for child and/or others 3
~ nowledge & Understanding of
t ftective Anger Management Strategies
3
1\, otivation for Change 3
lr sight & Self Awareness into
~ha,ioc
3
espectful attitude 4
erall Partic1pallon 4
i""""'
lm x Hostile, Aggressive Behavior
ustrated x Increased Depression
appropnateloccea,ed
Other Stm"
at None x
t
~ther
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xious
nfident
gretful
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glinical Contact Note
(b)(6)
qase Number 50539 Client Name:
Sfntact Date: 9/9/2009
Time Spent: 1.5 jType of Contact: In Person
~mber of Individuals Seen: 1
Type of Counseling Group: Offender Group jType of Session: Group
~ssion Notes:
oup Note/Participation Form
S 'ssion # 8
i Cpntent of Group: Family Differences
(: =none: 2=rarely; 3=sometimes: 4=often: 5=very often)
A~ceptance Of Responsibility 3
P~sonal Disclosures 3
E. pathy for child and/or others 3
Krowledge & Understanding of
~· ective Anger Management Strategies
D agnostic Impression
R commended Referrals:
In House FFSC: !External Military: IExternal Civilian: ITri-Care:
~IGNATURES
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(b)(6)
Thanks for the update. I'll wait to hear from you re: his discharge.
9.
(b)(6)
!
-t~-Qr1n1n~l f\Apc:c-:::lno ___ ~~
(b)(6)
Ftom.
Sfmt: 1- noav. JUIV j ·1 . LUU>J 1 h:tLI
Tp (b)(6)
Srbj8Ct: Kt· 1-0IIOW up on l-AP case
(b)(6)
!
rhanks for the email t regret to inform you tha: (b)( 6) is being processed out of the Navy. He's currently in an
utauthorizecf status so he's not available. I'll let you know the official date he is discharged so you can close the case.
VrR,
(p)(v)
(b)(6)
IUp0 AN lit I AM (CG b4)
(b)(6)
c·:rMM: (619)556-4497(0ffice)
C MM: (619)556-4495 (Qdeck)
A Sea: (619)545-8497 (Office)
A Sea: (619)545-3571 (Radio)
I
-·~-Original Messa~w---
P: m: (b)(6)
rr
$ ot '"'"·'""v (b)(6)
·""v ·"' '""""'41 AM
SfiJbJecl: 1-W: rollow up on FAP case
cl~c.
~1ent this to the wrong email address the first time.
(b)(6)
- -Orif:)inal MessaQe-----
F m: (b)(6)
S nt: 1nursdav. Julv 30. 2009 10:40
T : (b)(6)
0: (b)(6)
S bwcc ro11ow up on t-Al-' case
(b)(6)
I :fticed on the ship locator that the ship is back so wanted to follow up to see when (b)(6) would be able to
r~l~rn to the Men's group. He has completed 7 of 16 groups, and is in group Cypress which meets every Wed. from 1000-
11r0. I have CC'd h1m as well to remind him of the meeting times. Please let me know when he will return.
R.
(b)(6)
Ll ensed Marnage and Family TherapisUCase Manager Navy Family Advocacy Center
31 5 Oolpl1111 Alley, Bldg 261
S n Diego, CA 92136-5185
C MM: (619) 556-8315 DSN: 526-8315 FAX: (619) 556-9473
"F r Official Use Only- Pnvacy Sensitive" Any misuses or unauthorized disclosure may result in both civil and criminal
pe 1alties.
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dollateral Contact Note
C~se Number 50539 Client Name: (b)(6)
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Qontact Date: 7/30/2009 IClinical Provider: (b)(6) ITime Spent: 0.25
'
¢oNTACT
! (b)(6)
Cpntact Name:
A~~lateral Contact: GOVERNMENT
ENCY/ORGANIZATION
IType of Contact: Email
~pntact Notes:
Ernail send to CMC with SM cc'd.
i
(b)(6)
l~ot1ced on the ship locator that the ship is back so wanted to follow up to see when (b)( 6) would be able to
r turn to the Men's group. He has completed 7 of 16 groups. and is in group Cypress which meets every Wed from 1000-
1~ 30. I have CC'd him as well to remind htm of the meeting times. Please let me know when he will retum.
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(b)(6)
Ltensed Marriage and Family Therapist/Case Manager
N vy Family Advocacy Center
3f5 Dolph!O Alley, Bldg 261
S n Diego, CA 92136-5185
C MM: (619) 556-8315 OSN: 526-8315 FAX: (619) 55G-9473
"Ror Offic1al Use Only- Pnvacy Sensitive" Any misuses or unauthorized disclosure may result tn both civil and criminal
pralties
E IGNATURES
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~dministrative Note
(b)(6)
Cj)se Number 50539 Client Name:
Qontact Date:
Appointment Administration:
7ff30!2009
Firovider's Name: Administrative Notes:
(b)(6) Consull with new facilitator for Men's Group re. discrepancies in group log and CM's received case
1notes for group. Facilitator reviewed sign 1r1 sheets and stated SM also attended on 11/9/08, rnakmn 7
total attended. CM reviewed ship locator and ship has returned--tacllitator notified and CM will
1followup with command re: SM returning to group.
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clinical Contact Note
c+se Number 50539 Client Name: (b)( 6 l
Cqntact Date: 10/8/2008
Time Spent: 1.5 !Type of Contact: In Person
N4mber of Individuals Seen: 1
r)pe of Counseling Group: Offender Group !Type of Session: Group
S~ssion Notes:
G1pup Note/Participation Form
l
f.
(1 none; 2"rarely;3=sometimes;4"often:5=very often)
A~eptance Of Responsibility 3
P~rsonal Otsclosures 3
Er{lpathy for child andior others 3
Krowledge & Understanding of
Et ective Anger Management Strategies 3
M ltvalion for Change 4
In ight & Self Awareness into
BEhavior
3
REspectful attitude 3
0\ era II Part1crpation 3
Pl~n Status -
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Di~gnostic Impression
Re~ommended Referrals:
ln~~ouse FFSC: IExternal Military: IExternal Civilian: ITri-Care:
sjGNATURES
Si~nature of Provider: (b)(6) I Date of Signature: 12/9/2008
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~~ditional Comments or Closing Summary: SM talked about his anger and coping mechanism.
(b)(6)
' Status
P~an ,, ,,
~commended Referrals:
hi-House FFSC: I External Military: IExternal Civilian: ITri-Care:
,piG NATURES
f:iignature of Provider: (b)(6) IDate of Signature: 10/2/2008
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1--ontent of Group:
'\cceptance Of Responsrbillty 3
:>ersonal Disclosures 3
mpathy lor child and/or others 3
~nowledge & Understandtng of
ffective Parenting Strategies 3
~otivation for Change 3
nsrght & Self Awareness into
5ehavior 3
=iespectful attitude 5
:::>vera!! Participation 3
I
(b)(6)
Diagnostic Impression
, Recommended Referrals:
: In-House FFSC: !External Military: !External Civilian: jTri-Care:
, SIGNATURES
Signature of Provider: (b)(6) I Date of Signature: 1/22/2008
.
~linical Contact Note
(b)(6)
: ~ase Number 26353 Client Name:
; pontact Date: ,1/10/2008
ime Spent: 1.5 !Type of Contact: In Person
umber of Individuals Seen: 1
ype of Counseling Group: Oflender Group !Type of Session: Group
pession Notes;
p;roup Note/Participation Form
pontent of Group:
r-cceptance Of Responsibility 3
Personal Disclosures 3
mpathy for child and/or others 3
nowledge & Understanding of
ffect1ve Parenting Strategies 3
0otJvatJon for Change 3
rsight & Self Awareness into
ehavior 3
espectlul attitude 5
Dverall PartiCipation 3
I (b)(6)
0 agnostic Impression
R~commended Referrals:
1r House FFSC: !External Military: !External Civilian: jTri-Care:
~ IGNATURES
(b)(6)
S gnature of Provider J Date of Signature: 1i15/2008
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Page 16 or J7
' Contact Date: 12115/2007 j Clinical Provider (b)(6) j Time Spent: 0.25
CONTACT
(b)(6)
Contact Name:
1
(b)(6)
-·-~----------------------------------~
SIGNATURES
:;ignature of Provider: (b)(6)
j Date of Signature: 2n12007
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~ontent of Group:
r\CCeptance Of Responsibility 2
Personal Disclosures 2
mpathy for child and/or ot11ers 2
now/edge & Understanding of 2
: ·ffect1ve Parenting Strateg1es
1\otivation for Change 4
J 1sight & Self Awareness 1nto 3
ehavior
. espectful att1tude 3
Dverall Par11cipation 2
Diagnostic Impression
R~ commended Referrals:
In House FFSC: !External Military: !External Civilian: _ITri-Care:
E GNATURES
s,ignature of Provider. IDate of Signature: 12/7/2007
~
Collateral Contact:
Summary of Contact:
There IS uncertainty regarding whether SM's absences from group are excused, so vo1ce mail was left with SM requesting
1e call to update this writer about his schedule.
SIGNATURES
Signature of Provider (b)(6) Date of Signature: 11/30/2007
APPENDAGE NOTE
\lumber Appendage Note JProvider's Name Date
Received return call. SM stated having been underway and then on leave. (b)(6) 11/30/2007
He stated he will be at group next week. 5:19:00 PM
• Content of Group:
Acceptance Of Responsibrlity
Personal Drsclosures
Empathy for child and/or others
: Knowledge & Understanding of
Effective Parenting Strategies
, Motrvatron for Change
i lnsrght & Self Awareness rnto
'Behavror
Respectful attrtude
pverali Particrpation
(b)(6)
ecommended Referrals:
I -House FFSC: !External Military: !External Civilian: ITri-Care:
..>IGN/;, TUFlES
ignature of Provider: (b)(6) j Date of Signature: 11/30/2007
Content of Group
: Acceptance Of Responsibility
, Personal Disclosures
Empathy for child and/or others
, Knowledge & Understanding of
Effective Parenting Strategies
Mot1vation for Change
Insight & Self Awareness into
: Behavro1
Respectful attitude
pverall Participation
! (b)(6)
Content of Group:
Acceptance Of Responsibility
Personal Disclosures
Empathy for child and/or others
. Knowledge & Understanding of
Effective Parent1ng Strategies I
· Motrvation for Change
' Insight & Self Awareness into
·Behavior
Respectful attitude
pverall Participation
(b)(6)
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P ·int All Form~
onlent of Group:
1.\cceptance Of Responsrbilrty 3
:Jersonal Disclosures 3
mpathy for child and/or others 3
nowledge & Understandrng of
lfectrve Parenting Strategres 3
~otivatron for Change 3
nsrght & Self Awareness into
Behavror 3
=iespectful attitude 5
Jverall Participatron 3
(b)(6)
· Diagnostic Impression
' Recommended Referrals:
In-House FFSC: !External Military: !External Civilian: lrri-Care:
SIGNATURES
·r---------------------------------------.---------------------------------------~
, Signature of Provider: (b)(6) I Date of Signature: 1/22/2008
1~Time
c~(o~n~t~a~ct~D~at~e~:~1/~1~0~/2~0~0~8----------------------------------~=---~~~~~~~~--------------j
Spent: 1.5 jType of Contact: In Person
umber of Individuals Seen: 1
ype of Counseling Group: Offender Group !Type of Session: Group
:session Notes:
;::>roup Note/Participation Form
pessron # 12
pontent of Group
cceptance Of Responsibility 3
ersonal Disclosures 3
mpathy for child and/or others 3
nowledge & Understanding of
·ffect1ve Parenting Strategres 3
llotrvatron for Change 3
nsight & Sell Awareness into
ehavio1 3
espectful attrtude 5
Dverall PartiCJpatron 3
I (b)(6)
D agnostic Impression
A9commended Referrals:
lr House FFSC: !External Military: )External Civilian: jTri-Care:
! IGNJ.\.TURES
S gnature of Provider: (b)(6) I Date of Signature: 1115/2008
(b)(6)
i 2/15/2007 Clinical Provider: Time Spent: 0.25
(b)(6)
~)?")tes:
6
/' (b)( )here from FRCSouthwest formerly AIMD North Island. I have an upcoming CRC review on the 20th for now(b)( 6)
(b)( 6 ) 1/ound out today he made his court appearance yesterday and .was awarded probation for 3 years and
~ommunity service hours. He also was starting his group induction class this morning.
ust wanted to touch base with you before the Crc since I will be coming rn from leave to attend.
1
·--~)(""1----------------------------------i
SIGNATURES
ignature of Provider: (b)(6) Date of Signature: 2/7/2007
~ontent of Group:
~cceptance Of Responsibility 2
-ersonal Disclosures 2
mpathy for ch1ld and/or others 2
nowledge & Understanding of 2
·ffectJve Parenting Strateg1es
~otJvatJon for Change 4
J 1sight & Self Awareness 1nto 3
ehaVIOf'
espectful att1tude 3
verall Par11Cipat1on 2
Dipgnostic Impression
R commended Referrals:
In House FFSC: !External Military: !External Civilian: jTri-Care:
$.GN/l,TURES
Signature of Provider: (b)(6) IDate of Signature: 12!7/2007
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Collateral Contact:
Summary of Contact:
There IS uncertainty regardmg whether SM's absences from group are excused, so vo1ce mail was left with SM requesting
'le call to update this writer about his schedule.
SIGNATURES
Signature of Provider: (b)(6) Date of Signature: 11/30/2007
IIPPEND/~GE NOTE
Number Appendage Note !Provider's Name Date
Received return call. SM stated having been underway and then on leave. (b)(6) 11/30/2007
He stated he will be at group next week. 5:19:00 PM
I
IClinical Contact Note
Case Number 26353 Client Name:
(b)(6)
Content of Group:
Acceptance Of Responsibrlity
Personal Drsclosures
Empathy lor child and/or others
f\nowledge & Understanding of
: Effect1ve Parentmg Strategies
I
tv1ot1vat1on tor Change
lns1ght & Self Awareness rnto
. Behav1or
' Respectful att1tude
. Overall Participation
(b)(6)
ev1sed 712006.'
Jan Status
iagnostic Impression
ecommended Referrals:
External Military: External Civilian: Tri-Care:
:>IGNATURES
Content of Group·
Acceptance Of Responsibility
, Personal Disclosures
: Empathy for child and/or others
Knowledge & Understanding of
Effective Parenting Strategies
Molivation for Change
Insight & Self Awareness 1nto
Behav1or
Respectful attitude
Overall Pari1cipation
(b)(6)
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Page :23 of 37
Content of Group:
• Acceptance Of Responsibility
Personal Disclosures
' Empathy tor child and/or others
Knowledge & Understanding of
: Effective Parenting Strategies
. Motivation for Change
, Insight & Self Awareness mto
Behavior
pespectful attitude
pverall Part1cipat1on
(b)(6) ----
( ev1sed 7/2006,,.!(blf[()
A commended Referrals:
lr House FFSC: lExternal Military: IExternal Civilian: jTri·Care:
"IGNI\TUFJES
S gnature of Provider: (b)(6) IDate of Signature: 11 /13/2007
pontent of Group:
[\cceptance Of Responsibility
Personal Disclosures
mpathy for child andtor others
r-nowledge & Understanding of
ffective Parenting Strategies
~otivation for Change
nsight & Self Awareness into
pehavior
~espectful attitude
pverall Participation
I
t;linical Contact Note
(b)(6)
pase Number 26353 Client Name:
~ontact Date: 10/25/2007
lfime Spent: 0 jType of Contact:
Number of Individuals Seen: 0
11 ype of Counseling Group: Offender Group {Type of Session: Group
~ession Notes:
~roup Note/Participation Form
(b)(6) 'Case Manager:(b)( 6)
pate: 10/25/07 Client's Name
U:>)~;)
~r
pess1on # Absent
pontent of Group:
cceptance 01 Responsibility
ersonal Disclosures
mpathy for child and/or others
nowledge & Understanding of
ffective Parenting Strategies
~otivat1on for Change
1sight & Self Awareness mto
ehav1or
espectful attitude
)verall Pa1iicipat1on
(b)(6)
----
lecommended Referrals:
I -House FFSC: !External Military: !External Civilian: fTri-Care:
piGNATUf-lES
~ ignature of Provider: (b)(6) J Date of Signature: 10/26/2007
.,
J:linical Contact Note
(b)(6)
pase Number 26353 Client Name:
f:;ontact Date: 10/18/2007
ifime Spent: 1.5 !Type of Contact: In Person
~umber of individuals Seen: 1
rrype of Counseling Group: Offender Group !Type of Session: Group
~ession Notes:
Group Note!Partic1pat1on Form
~onten1 of Group:
iclcceptance Of Responsibility
Personal DisClosures
._mpathy for ctlild andfor ottlers
Knowledge & Understandmg of
Effective Parenting Strategies
rv1ottvation for Ctlange
nsight & Self Awareness into
Bet1av1or
Respectful attitude
Overall Participation
---·-
(b)(6)
Revised 7/20Db
...,._,.-
!Pian Status ',: l', ·;;,;I, ! '~ '; ' '' '' .,
" •'.,;\:
fecommended Referrals:
n-House FFSC: !External Military: !External Civilian: ITri-Care:
SIGNATURES
,-~------ ----
Signature of Provider: {b){6)
I Date of Signature: 10/19/2007
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Page 27 or 37
~dministrative Note
~ase Number 26353 Client Name: (b)(6)
Administrative Notes:
Case transferred to (b)(6)
cceptance Of Responsibility
ersonal Disclosures
rnpathy for child and/or others
nowledge & Understanding of
.flective Parenting Strategies
~otivation for Change
llSiQil! & Self Awareness into
'ehavior
espectful altitude
Dverall Participation
(b)(6)
I[ iagnostic Impression ~ ! ~ !~ c- ;
'''·'·''''·; , ' ~ .
\
ecommended Referrals:
Jr -House FFSC: !External Military: !External Civilian: ITri-Care:
p1GNATUF1ES
Collateral Contact:
Summary of Contact:
TC from S) M: reports he was on duty 27Sep071herefore could not attend group. SM excused. (b)(6) Informed group
eader (b (B)
SIGNATURES
(b)(6)
Signature of Provider: Date of Signature: 9/28/2007
i Administrative Note
(b)(6)
Case Number 76567 Client Name:
, Contact Date: 3/10/2009 Appointment Administration:
·. Provider's Name: (b)(6)
(b)(6) Administrative Notes:
'II TC with ADM to request copy of confirmation of attendance rn 52-Week Men's Offenders
Group. ADM will fax confinnation today.
IL-----'--------------l
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'~ollateral Contact:
rcummary of Contact:
, Case management sess1on with SM who is requesting a court letter regarding how he attended FAG Educat1on Sess1on. He
"ported how he starts the DVRP 52 week program tomorrow, due to being out on convalescent leave. He was attending AA
eellngs. He said the plan is for the CW and the children to live in the state of Texas temporarily.
' (b)(6)
~ignature of Provider Date of Signature: 8/28/2007
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t'agc l. o l (1
1 Collateral Contact:
' Summary of Contact:
4/12/06: Case went to CRc and was substantiated SM is attendmg a 52 week DVRP. Command was not present because
unit was decommissioned and letter was returned.
4/14/06· Message left for SM
:
; ~ f ~ I~
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(b)(6)
1 ontact Date: 3/15/2007 Clinical Provider:
4 ollateral Contact:
: ,------
ummary of Contact:
5 March 2007
1 ~to SM @ (b)( 6) to 1nform hlfn that the case closed. He confirmed that his new command 1s Center for Naval Civil
1Ef1g1nf)ering, Bid 3294.
I( fficer in charge. He will come 111 next week to PU tr1e close letter and provide documentation of h1s court attendance HIS
IV~prk hours: 7-2
j·.: ''
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f--'-
E ignature of Provider (b)(6) Date of Signature: 3i15/2007
~ollateral Contact:
-
:summary of Contact:
14 March 2007
0 rev1ew this date Closed as resolved.
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~'""""' Nole
Case closed before close letter produced. As a result, letter not scanned Into
.\PcwideC" Nome
(b)(6)
Date
6/21/2007 10:35:00
, record. AM
·'----------
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Clinical Contact Note
ase Number 11947 Client Name: (b)(6)
_,_~·--··-
--
:ontact Date: 3/13/2007 Clinical Provider: (b)(6)
ollateral Contact:
-------- -
t>ummary of Contact:
13 March 2007
· ~ to SM @ work. to determme court status Still continumg on sessioin 39. Court last month. He Will drop off his
purt pv-<.
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1 ollateral Contact
t-~·
~ummary of Contact:
PO December 2006
9) day rev1ow til is date
If\
pxt "' 03-14-07.
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~ AP Clinical Contact Note
(b)(6)
( ase Number 11947 Client Name:
(b)(6)
vontact Date: 10/4/2006 Clinical Provider:
--
ime Spent: 3 Type of Contact: Other
----
:oflateral Contact:
• 3ummary of Contact:
· 29 September 2006
' C to SM at horne number, (b)(6) He said that he has attened 24 sessions and his next court date on 24 October.He will
rov1de PW afterward.
e has changed offices and the new number is (b)(6)
October 2006
p day review th1s date.
ext'' 12/20/06.
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---
Summary of Contact:
24 August 2006
OV by SM He proVIded DVRP update for 90 day rev1ew on 10/4 He has completed 14 groups and 1s making excellent
progress. He should complete the class in March 07. He saicJ H1at he and h1s w1fe are still separated as t1e struggles to accept
, her for cheat1ng on him.
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FAP Clinical Contact Note
Case Number 11947 Client Name: (b)(6)
-~-
(b)(6)
Contact Date: 7/12/2006 Clinical Provider:
--·-
Time Spent: 3 Type of Contact:
Collateral Contact:
Summary of Contact:
28 June 2006
·c to SM's 11ome number. Not working.
(b)(6) new CFR. TC to command, (b)(6) He located SM. He will got on 1t and call me back.
)9 June 2006
C to SM at his new work number (b)(6) He said that he has to request PW 3 weeks m advance and he probably can't
pet PW by the 90 day review. H1s next court end of July He said he's been going two months and has attended about 8
ess1ons and he really struggling to pay all the bills.
2 July 2006
0 day rev1ew this date- ~~ext 1s 4 October.
r n >· -·-----· --
!signature of Provider: (b)(6) Date of Signature: 7/12/2006
~-
Collateral Contact:
·--
Summary of Contact:
•
TC wtth SM. He reported that he was released from the Navy on 7/24/06. He was moving to Maine and was planning on
. divorcing t1is Wife. He reported no new tncidents of v1olence. Discussed upcoming committee meetmg to close his case out,
but that it would be unresolved as he did not complete the recommended treatment.
',';'
-- (b)(6)
Signature of Provider Date of Signature: 7'26/2006
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I!Administrative Note
6
Case Number 14509 Client Name: (b)( )
Contact Date:
Appointment Administration:
p/23/2006
Provider's Name:
(b)(6) Administrative Notes:
Notified SM by phone that he IS enrolled in Group Hawk, conducted at FAP San Diego, beginning
at 0715 on 06-06-06, and that groups will meet every Tuesday from 08-1000 thereafter, for a total of
II 16 weeks.
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Contact Note
(b)(6)
~ase Number 60118 Client Name:
l~ontact Date: 6/10/2009
Itime Spent: 0 jType of Contact:
!
fi~umber of Individuals Seen: 0
Iype of Counseling Group: jType of Session:
ession Notes:
troup Note/Participation Form
~)~)continues to participate appropriately. He does not usually disclose his thoughts without
fPrompting, but is attentive and involved in the process. He listens carefully and is engaged in
the group.
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cf:<evised 7/2006 !~
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~Jan Status r Continue Treatment Plan r /\ltered r reatrnent Plan
$iagnostic Impression r UnclBnged r RevJ::;ed
lfRecommended Referrals:
l.n~House FFSC: I
External Military: !External Civilian: jTri~Care:
JsiGNA TURES
Signature of Provider: (b)(6) j Date of Signature: 6/10/2009
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~ession # 3
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~ontent of Group:
~
1 =none; 2=rarely; 3=sometimes; 4=often; 5=very often)
2 3 4 5 N/A
-. cceptance Of Responsibility 4
personal Disclosures 4
mpathy for child and/or others x
!
nowledge & Understanding of
ffective Parenting Strategies x
otivation for Change 4
sight & Self Awareness into
Sehavior4
'
Eespectful attitude 4
pverall Participation 4
!
Jl.FFECT THERAPEUTIC CONCERNS
~pbeat x Incident of Re-abuse
.
f:;uarded Suicidality
esentfullncreased .Risk of Re-abuse
~
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Clinical
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Contact Note
(b)(6)
Case Number 60118 Client Name:
~ontact Date: 5/13/2009
Time Spent: 2 !Type of Contact: In Person
l
~umber of Individuals Seen: 1
type of Counseling Group: Offender Group IType of Session: Group
!
Session Notes:
~roup Note/Participation Form
I
pate: 13 May Client's Name: (b)(6) Case manager: (b)( 6l
I
~roup Name: _Cypress Group Leader(s): _ (b)(6)
!
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Session# 3
!
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q:;ontent of Group:
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=none; 2=rarely; 3=sometimes; 4=often; 5=very often)
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2 3 4 5 N/A
cceptance Of Responsibility 3
ersonal Disclosures 4
~mpathy for child and/or others x
~nowledge & Understanding of
ffffective Parenting Strategies x
~otivation for Change 4
Insight & Self Awareness into
~ehavior 4
ijespectful attitude 4
Qlverall Participation 4
!
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AFFECT THERAPEUTIC CONCERNS
ljpbeat Incident of Re-abuse
Quarded Suicidality
f1esentful Increased Risk of Re-abuse
c}alm x Hostile, Aggressive Behavior
ftustrated Increased Depression
!1eflective x Increased Stress
!~appropriate Other
AatNone ----------------
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.tf1gry
~d
1\Pxious
obnfldent
R,bgretful
Qther
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cceptance Of Responsibility 3
, ersonal Disclosures 3
ffmpathy for child and/or others x
~nowledge & Understanding of
ijffective Parenting Strategies x
f\t1otivation for Change 3
!~sight & Self Awareness into
'
~ehavior 4
Jlespectful attitude 4
qverall Participation 4
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(b)(6)
participation was very good for a first day. He seemed unsure of what to expect, but
~oon relaxed and interacted well with other group members. He shared the incident that
~ought him to the group as well as the insight he has developed since.
ate:
~ecommended Referrals:
In-House FFSC: !External Military: !External JTri-Care:
fAP Civilian:
!SIGNATURES
)Signature of Provider: (b)(6)
-··--·-·
IDate of Signature: 5/6/2009
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I FAP Clinical Contact Note
ICase Number 54017 Client Name: (b)(6)
(b)(6)
Clinical Provider:
Collateral Contact:
Summary of Contact:
Mel w1th SM and provided him with a fetter for the Superior Court of San D1ego indicattng that he is scheduled to begm DV
x., 20 Jun 08. SM denies having any alcohol s1nce February, 2008 and reflected upon his inpatient treatment program. SM
tated that his parents w1ll be attending the child custody hearing scheduled for 6 Jun 08 at wh1ch time they will request that
is son be in their custody temporanfy, where they reside in North Carolina. SM is to inform this CM regarding the outcome of
he court hearing. Discussed the content of the men's offender group and encouraged SM to partic1pate as fully as possible.
M is to begin by attending the educational session, 20 Jun 08.
l SiGNA :s
!signature of Provider (b)(6) Date of Signature: 5/27/2008
~-
. Collateral Contact:
Summary of Contact:
The following email was sent today to CFAR, (b)(6)
(b)(6)
is assrgned to nrm '" r.'tpress which meets each Wednesday from I 000-1130 at the
l-AC, San Diego Naval Base, buildrng 261. Since (b)( 6 ) rs scheduled to attend the educational SP.SSIOn 20 ,Jun 08 @
0830-1200 hrs., he may attend his first sessron wrth Grp Cypress, 25 Jun 08. I will contact (b)(6) next week to inform
hrm Thank you very much for your assistance.
y!r
(b)(6)
f'fAP Case f>1anager
IJ'iaval Base San Diego
pomrn:619·556-6438
DSN: 526-6438
Fax: 619-556-9678
' trc1al Use Only- Pnvacy Sensrtrve" An}' mrsuses or unauthorized drsclosure may result rn both crvrl and cnminal
es.
6
ure of Provider: (b)( ) Date of Signature: 5/23/2008
.navy.mi1/components/forms/PrintAllforms.a'>px 12/27/2010
Page 8 of 21
rc~~lateral Contact:
~~ummary of Contact:
l Spoke with SM today to inform him that this CM prepared a letter for the Superior Court of San D1ego related to h1s
!upcoming DUI hearing, 6 Jun 08, Indicating that he will be attending a DV series at the FAG; copy of letter IS below. SM 1s
!scheduled to p/u letter, 27 May 08 @ 0930 hrs.
~
frO: SUPERIOR COURT OF SAN DIEGO
t
tROM: F/l.MIL Y ADVOCACY {;J='NTER, SAN DIEGO NAVAL BASE
RE . . (b)(6) DUI HEARING ol 6 JUNE 2008
Iil
b.A.·I t: · 2:J MAY 2008
!his 1s to confirm that (b}(S) 1s scheduled to begin a s1xteen sess1on men's offender group in domestic
.,~iolence. 20'' "' ?nnQ (b )(S) 1as expressed an eagerness to beglfl th1s treatment series and to complete 11
$uccessfully (b)(S) Command is supportive and is expected to make the necessary provisions which will permit him to
l.ttend the sones regularly. I am available for any further inquiry. Thank you for your consideration.
It
~ery Rospectfully,
(b}(6)
Gase Manager
Base San Diego
Dolpt11n Alley, Building 261
Diego. CA 92136-5185
9-556-6438
619-558-9678
(b)(6)
I
Date of Signature; 5/23/2008
Administrative Note
Case Number 54017 Client Name: (b)(6)
Contact Date:
Appointment Administration: Not applicable
5/5/2008
~--~~~----~--~--~~--------------------------------------------------------~
Provider's Nl'lm"!: Administrative Notes:
(b)( 6 ) The following email was sent to CFAR, (b)( 6 ) today:
(b)( 6 ) : S1nce the San D1ego County JUdge recently dismissed (b)(e) requirement to
attend a court approved DV coursfl h"'(b)('bf" "'ligible to attend the 16 sess10n therapeutic DV program
at the FAC. To begin this program, must first attend an Educational Session which is
scheduled for 20 Jun 08 from 0830-1200 11rs. Thank you very much.
v/r
(b)(6)
rAI-'case Manager
Naval Base San Diego
Comm :619·556-6438
DSN: 526-6438
Fax: 619-556·9678
"For Offic1al Use Only- Privacy Sensitive" Any misuses or unauthorized disclosure may result 1n both
civil and criminal penalties .
.mii/componcnts/fonns/PrintAI!Fornls.aspx 12/27/2010
Page 12 of2l
Collateral Contact:
Summary of Contact:
Received phone call from SM today who stated that he attended the child custody court hearing yesterday, with h1s
attorney. SM reported that the court dismissed the requirement for him to attend a "court ordered" program s1nce the court
awarded custody of his child to the child's mother, partly because SM did not complete the requirement 1n the year allotted.
SM stated that he decided to withdraw his request of a review of his case and expressed interest 111 attendrng the 16 week
men's offender group at the FAC. Informed SM that he will be placed on waiting list and will therefore attend somet1me after
his SARP inpatient treatment. SM expressed agreement.
navy.millcomponents/forms/PrintAilForms.aspx 12/27/2010
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Collateral Contact:
Summary of Contact:
CRC held today with Command representation. SM was substantiated for partner abuse toward ex-girlfriend. Spoke with SM
to discuss the 52 week State of California DV course he has been mandated to attend since March 2007. This CM did not
discuss anything specifically about the CRC held today. SM verified that he has not attended any of the mandated classes.
Informed SM that he will be given an additional 30 days to enroll and begin attendin( from this date; SM expressed
aareement. Provided the following to SM: Alpha Behavioral Health Services: i b)(r,;,)
· · (1) ( (Q) as this is an approved provider.
SIGNATURES
Signature of Provider: (b)(6) Date of Signature: 315/2006
'
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Page 4 of 30
P~n Status
~-·
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•
D~gnostic Impression . : . .. :
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Page 5 of 30
\Administrative Note
jCase Number 55987 Client Name: (b)(6)
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Page 6 of' 30
of Individuals Seen: 1
of Counseling Group: Offender Group
Session Notes:
proup Note/Participation Form
(b)(6)
Date of Signature: 718!2008
inistrative Note
(b)(6)
(b)(6)
Session Notes:
Group Note/Participation Form
Flat
Angry
flosentfuiSad
Calm x Anx1ous
Frustrated Confident
P.eflectlvo Regmtlul
~)ther (stale type):
THEFlAPEUTIC CONCERNS;
lnc1dent of Re-abuse
~~U!CicJaJity
lt1creased Risk of Re-abuse
l
ftostdo, Aggrossivo Bohavior
Depression
Stress
X
COMMENTS or <::1 IMhAhOV: : SM reported tllat he has llad a good week. He participated in discussion of weekly top1c.
(b)(6)
(b)(6)
Contact Note
(b)(6)
or SUMMARY:: SM reporiod that he has had a good week. He participated in discussion of weekly topic. He
H1at h1s oartnm anrl f)e continue getting along since she has been attending parenting classes.
(b)(6) ' '
He has completed 10/10 sess1ons of Group KuhlanL Thoro flavo not boon
Contact Note
(b)(6)
Flat
Guarded Angry
Flesentful Sad
Qalm x Anxious
F'Yustrated Confident
Flefleclive Regretful
Other (state typo)
THERAPEUTIC CONCERNS:
lrJcJdont of Ro-abuse
Suicidali!y
Increased H1sk of Flo-abuse
Hhstile, Aggressive Behavior
Increased D0pression
lnheased Stress
Other:
Nono x
OOMMENTS or SUMMARY: · SM reported that he has had a good week. He stated that his partner started attend1ng
pclrenting group and he IS notic1ng a pOSitive change in her behavior towards hwn.
(b)(6)
Signature: 6/13/2008
Contact Note
(b)(6)
Client ilad fmal session and shared l11s progress and information that he has learned in group on positive
Client states that he recognizes where his FOO issues need to be addressed. Client reports that llo doesn't want
samo mrstakes h1s parents made
n Contact Note
· Case Number 55987 Client Name: (bJ( 6 )
Note/Participation Form
5/28/08
(b)(6)
Narne: (b)(6) Case Manaqer
(b)(6)
r~arne: Knu1an1 I Group Leader{s).
Attended: 9 Absent: Halfway po1nt: F1nal Session.
of Group· One now group member attended group today. Group members checked in w1th facilitators regardmg
rofornng 1ncidents and descript1ons of their styles of parenting and •vhat they need to work on. Topic of group was parenting
handouts were discussed and processed by all group merntJers Group member's shared individual situations ancJ
techniques that work with parenting skills
a number value to each category: honone; 2=rarely; 3:=sometimos; 4=often; or N/A Acceptance of Responsibility: 3
Disclosures: 2
for others: 2
OWieCIOO & Understanding Of
Strategies: NA
for Change: 3
attitude: 3
Participation: 2
an ·'X" for those that apply: AFFECT:
H1sk of He-abuse
Stress
Client appeared quiet and guarded in group. Client offered min1malmformation in sharing h1s expenences w1th
nwthods.
(b)(6)
attrtude: 4
or SUMMARY: · SM partrcipated rn the accountabrlity exercise. He descrrbed the part he played in tho incrdent
referred him to FAP, took responsibility for hrs part. and reflected on what he could have done differently.
(b)(6)
Note
Case Number 55987 Client Name (b)(G)
(b)(6)
I
1, ;dministrati~~ ~:;:~~--~~ ··~-~···-·· ..
Case Number 55987 Client Name: (8 H6 l
1 ------~--------------------------,
.I Contact Date: 5/13/2008 Appointment Administration: Cancelled
I Provider's Name: (b)( 6) Administrative Notes:
(b)(6) Group Note/Participation Form
(b)(6)
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Assign a number value to each category: 1=none; 2=rarely; 3=sometimes; 4:::often; or N/A
Acceptance of Responsibility: 3
Personal Disclosures: 4
Empathy for others: 3
Knowledge & Understanding of
Effective Parenting Strategies: NA
Motivation for Change: 3
Respectful attitude: 3
Overall Participation: 3
Put an "X" tor those that apply: AFFECT:
Upbeat
Guarded
Resentful
Calm X
Frustrated
Reflective X
Inappropriate
Flat
Angry
Sad
·Depressed
Anxious
r:;onfident
flegrettul
pther:
herapeutic Concerns:
ncident of Re·abuse
::>Uicidality
ncreased Rtsk of Re-abuse
1ostlle, Aggressive Behavior
hcreased Depression
~creased Stress
¢omments: Client appeared attentive but quiet dunng group discussion about FOO issues.
~ill have hatfwa~ check in next week. Due to time constraints all members were not able to share FOO questionnatre.
ecommended Referrals:
I -House FFSC: TExternal Military: !External Civilian: !Tri-Care:
SIGNATURES
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Page 19 of 30
rI
ther:
MMENTS or SUMMARY: SM reported that he wanted to move the rest of his things out of girlfriend's apartment and he
s fearful there might be another incident. He called his pastor who came with him. GF was not home. He was
ngratulated by the group for tak1ng positive steps to avoid a confrontat1on.
I
(b)(6)
Pljm Status C~v!n1n; .f· -~I C:t:t!rn(T!; F'!tll: Aitt:nur: Trc:ntrr·.ent F1 Jn:n
RE commended Referrals:
hr ~ouse FFSC: External Mllltary:I IExternal Civilian: jTri-Care:
S GNATURES
Si~nature of Provider: (b){6) IDate of Signature: 4/30/2008
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Page 20 of 30
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l Clinical Contact Note
I Case Number 55987 Client Name: (b)(6)
I' Time
Contact Date: 4/23/2008
jTl::pe of Contact: In Person
Ii Number of Individuals Seen: 1
Spent: 1 .5
j
Assign a number value to each category: 1=none; 2=rarely; 3=sometimes; 4=often; or N/A
Acceptance of Responsibility: 3
Personal Disclosures: 4
Empathy for others: 3
Knowledge & Understanding of
Effective Paranting Strategies: NA
Motivation for Change: 3
Respectful attitude: 3
Overall Participation: 3
Put an "X" for those that apply: AFFECT:
Upbeat
Guarded
Resentful
Calm X
Frustrated
Reflective X
Inappropriate
Flat
ft'.ngry
~ad
rP'""''
nXIOUS
onfident
egretful
j:)ther;
frherapeulic Concerns:
ncident of Ae-abuse
roidallly
creased R1sk of Re-abuse
ostile, Aggressive Behavior
creased Depression
. creased Stress
omments: Client appeared attentive but quiet during group discussion about FOO issues .
. Viii have halfway check in next week. Due to time constraints all members were not able to share FOO questionnaire.
ian Status Contn,LH"· ·r rr;uin1en: PL·J: i !\!i_(;; ("(i Tlc~ntn1cnt F1 ldn
ecommended Referrals:
I -House FFSC: .!External Military: lExternal Civilian: jTri-Care:
piG NATURES
~ignature of Provider:
(b)(6)
IDate of Signature: 5/22/2008
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I Clinical Contact Note
j Case Number 55987 Client Name· (b)(6)
r
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OMMENTS or SUMMARY: SM talked about a recent incident while out with a command farewell party. Someone tried to
ro~oke him into a fight and he was able to resist. He states that he was not drinking and it helped him to make the right
eCISIOn.
(b)(6)
lftecommended Referrals:
l
1(1-House FFSC: IExternal Military: !External Civilian: !Tri-Care:
ltGNATURES
$ignature of Provider: (b)(6) j Date of Signature: 4.'23/2008
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I Clinical Contact Note (b)(6)
I C ase N urn b er 55987 Cl'1ent Na me:
Contact Date: 4/16/2008
Time Spent: 1.5 jry~e of Contact: In Person
Number of Individuals Seen: 1
Type of Counseling Group: Parenting !Type of Session: Group
Session Notes:
Group Note/Participation Form
Date: 4/16/08 {p ){f:. \ (b)(6)
Client's Name: , I Jl Case Manaaer: (b)(6)
Group Name: Khulani I Group Leader(s):
Sessions Attended: 4 Absent: Halfway pullll. rllll;ll ::.eSSIOn:
Content of Group: All members shared introductions of referring incident due to one new group members today. Video on
anger and DV was shown for 30 minutes. Group facilitators gave handouts on Anger and discussed theW's of lime outs and
coping skills to deal with anger. Group addressed their own triggers to anger and how it affects their relationships with
spouse and children. Facilitators assisted members with processing their personal coping skills.
Assign a number value to each category: 1=<none; 2=rarely; 3=sometimes; 4=often; or N/A
Acceptance of Responsibility: 3
'Personal Disclosures: 4
$Empathy tor others: 3
~nowledge & Understanding of
~ffective Parenting Strategies: NA
~otivation for Change: 3
=iespectful attitude: 3
:::>verall Participation: 3
Put an "X" for those that apply: AFFECT:
~pbeat ·
~uarded
rsonHul
aim X
rustrated
eflective X
lpappropriate
~Ingry
at
ad
~pressed
XIOUS
~nfident
gretful
her:
~erapeutic Concerns:
I ident of Re-abuse
S~icldality
l~reased Risk of Re-abuse
H stile, Aggressive Behavior
~reased Depression
reased Stress
mments: Client appears attentive and participatory in group when called on. Client shared how he has conflict m
re FJiionship and uses time out's to calm him.
PI ~n Status .~:t~!llil.lLL~' ·:·f f~:.:1trnC<i' r·_)l{H-; l'-·d\>~:!'.~C~ Tu.-t:i:nJ(:rr r:·tcl!·
R*ommended Referrals:
In· -louse FFSC: I External Military: !External Civilian: ITri·Care:
S GNATURES
Si nature o1 Provider: (b)(6)
IDate of Signature: 5/22/2008
l
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Page 23 of 30
I
i!
1 Ad . . . Note
1 mmastrattve
I Case Number 55987 Client Name: (b)(6)
I Provider's Name:
(b)(6)
(b)(6) Administrative Notes:
Group Note/Partictpa!ion Form
Content of Session:
Assign a number value to each category: 1,_none; 2=rarely; 3:::sometimes; 4=often; or
N/A
Acceptance of Responsibility:
Personal Disclosures:
Empathy for others:
Knowledge & Understanding of
Effective Parenting Strategies:
Motivation tor Change:
Respectful attitude:
Overall Participation:
Put an "X" for those that apply:
AFFECT:
Upbeat Flat
' Guarded Angry
I Resentful Sad
l
l
Calm Anxious
Frustrated Confident
l
I
I
Reflective Regretful
Other (state type):
THERAPEUTIC CONCERNS:
Incident of Re-abuse
Suicidality
Increased Risk of Re-abuse
Hostile, Aggressive Behavior
l Increased Depression
Il Increased Stress
Other:
I None
COMMENTS or SUMMARY:
I
j
I' I (b)(6)
I
I
\
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Page 24 of 30
Assign a number value to each category: 1=none; 2=rarely; 3=sometimes; 4:::often; or N/A
Acceptance of Responsibility: 3
Personal Disclosures: 4
Empathy tor others: 3
Knowledge & Understanding of
Effective Parenting Strategies: NA
Motivation tor Change: 3
Respectful attitude: 3
Overall Participation: 3
Put an "X" tor those that apply: AFFECT:
Upbeat
puarded
~"enrtul
aim X
rust rated
eflective X
~appropriate
lat
tngry
ad
!Depressed
4-nxious
~ontident
t~:""'
herapeut1c Concerns:
cident of Re-abuse
uicidality
~creased Risk of Re-abuse
ostile, Aggressive Behavior
creased Depression
lrlcreased Stress
~~mments: Client appears to take more responsibility for his past in refernng incident. Client shared his tnggers to anger in
relationship. Client was also participatory in group.
Plan Status C~oniJn\lci 'f ru:-:;t1nlent Pinr: /\\loi ud -1 1c~·lt!lH:::>nt Pi~P·\
A commended Referrals:
In House FFSC: TExternal Military: !External Civilian: jTri-Care:
~IGNATURES
S~nature of Provider: (b)(6) j Date of Signature: 5/22/2008
i
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Page 25 of 30
--
Assign a number value to each category: 1=none; 2=rarely; 3=Sometimes; 4"'otten; or N/A
Acceptance of Responsibility: 3
Personal Disclosures: 4
Empathy for others: 3
Knowledge & Understanding of
!Effective Parenting Strategies: NA
Jvlotivation for Change: 3
~espectful attitude: 3
verall Participation: 3
ut an "X'' for those that apply: AFFECT:
~pbeal
uarded .
~esentlul
Calm
~rustrated X
1}1eflect1ve X
!:fpmp,iato
ngry
ad
epressed
~nxious
aonfident
egretful
ther:
Tperapeut1c Concerns:
lrlcident of Re-abuse
~~icidality
I reased Risk of Re-abuse
Hpstile, Aggressive Behavior
lntreased Depression
In reased Stress
~mments or Summary: Client's second session and he appeared very open and honest about his concerns with his
at1onsl1ip. Client was able to identify need to work on trust between him and partner. Client also identified cycle of violence
in .,is current relationship. ·
Pl~n Status (;, ... ,ill' hie' .ll(:->C.li!l!C!.li r-t"Pl /\1\('l ~:·n ~~ ~t>Jttn·:;n: f- 1 !~-tl:
Rdcommended Referrals:
lntJouse FFSC: !External Military: !External Civilian: jTri-Care:
SjGNATURES
Assign a number value to each category: 1=none; 2=rarely; 3:::Sometimes; 4=often; or N/A
Acceptance of Responsibility: 2+
Personal Disclosures: 3
Empathy for others: 3
Knowledge & Understanding of
!Effective Parenting Strategies: NA
· ~otivation tor Change: 3
espectful attitude: 3
pverall Participation: 3
Eut an "X" for those that apply: AFFECT:
pbeat
rded
esentful
aim X
$rustrated
eflective X
~appropriate
1tat
r pressed
XIOUS
nfident
gretful
c::jther:
T erapeutic Concerns:
lr lcident of Re-abuse
S~icidality
lr preased Risk of Re-abuse
H stile, Aggressive Behavror
lnpreased Depression
lnpreased Stress
C mments or Summary: Arrived on time for intake with facilitators. This was client's first session and he appeared quiet
hcrever did earticipate when called on. Client was attentive and cooperative in groue.
Pl~n Status ' Cont!l'i\if:· ; t (·:~ttrncnt Pl::-1n !.\.He;:-)(! Ttu: !ll:Uii' r.::L-;!:
A! !commended Referrals:
In· House FFSC: IExternal Military: IExternal Civilian: /Tri-Care:
S GNATURES
Si,nature oi Provider: (b)(6) IDate of Signature: 5/2212008
\
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1
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Page 2 of 33
!lrlllll 11.11 rUHII:>
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Clinical Contact Note (b)(6)
Case Number 58410 Client Name:
Contact Date: 3/10/2009
Time Spent: 1.5 !Type of Contact: In Person
Number of Individuals Seen: 1
Type of Counseling Group: Offender Group !Type of Session: Group
Session Notes:
Group Note/Participation Form
Session# 12
Content of Group:
(b)(6) :>articipated very well and offered disclosure as well as accepted feedback from others. Seemed to benefit from the
· mauer group size. Little to no profanity today!
~
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(b)(6)
Signature of Provid.,r Date of Signature: 3/1 0/2009
II,,
II
•
II
~ession # 11
pontent of Group:
Session#
I
Llinical Contact Note
tase Number 58410 Client Name· (b)(6)
teSSIOn !17
l ontent of Group:
II!I
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Page 9 or 33
II.,
,,
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I
Session# 7
Content of Group:
i:
il\:irlilinn'll Comments or Closing Summary: .
,~) {y) noted that CW drank over the weekend and became agitated and offensive, as she usually does. SM was able to
ooallicl, a ad avoided aJoohol coaoumplioa throughOul I he weekead,. The gmup offemd supportive Jeedback
~ commended Referrals:
I~ House FFSC; IExternal Military: !External Civilian: jTri·Care:
!· jQf.J!\TUHES
~~nature of Provider: (b)(6) IDate of Signature: 2/12/2009
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l Clinical Contact Note
(b)(6)
I Case Number 58410 Client Name:
Contact Date: 2/12/2009
I
I
Time Spent: 1.5 \Type of Contact: In Person
I Number of Individuals Seen: 1
I !Type of Session: Group
Type of Counseling Group: Offender Group
I Group
Session Notes:
Note/Participation Form
II
I Date: 4 Feb 2009 Client's Name: (b)(6) Case Manager: (b)(6)
i Session
I
II 9 Content of Group:
I
J (1 =none; 2=rarely; 3:sometimes; 4=often; 5=very often)
; 1 2 3 4 5 N/A
IAcceptance Of Responsibility x
Personal Disclosures x
Empathy for child and/or others x
\ Knowledge & Understanding of
'Effective Parenting Strategies x
I !Motivation for Change x
l nsight & Self Awareness into
Behavior x
Respectful attitude x
Overall Participation x
\I
II
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Page 12 of 33
Session# 10
Content of Group:
~
erall Partictpation x
~
ge problem 1n the marnage, and SM appeared relieved. Members offered supporttve feedback.
I
I
te. ~ 11 Feb 2009. _ _ _ _ _ _ _ __
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Signature of Provider: (b)(6) \ Date of Signature: 2/12/2009
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Page \4 of 33
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Session # 5
1
9espectful attitude 3
Dverall Partictpation 2
i''
\pappropr\ate Other
ngry
Nooe
ad
~nxious
onfident
egretful
~her
dit1onal Comments or Closino S1Jmmary: SM provided supportive feedback to other group members.
(b)(6)
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FAP Clinical Contact Note
(b)(6)
Case Number 92280 Client Name: ·--- "---·-·
(b)(6)
ContactDate: 8/16/2010 Clinical Provider:
Time Spent: 0 Type of Contact: Email
Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summary of Contact:
(b)(6)
(b)(6)
has deployed for more than 3 weeks now and will miss next
week's meeting. He will however be available the week after, starting 23
August. Please let me know if you have any questions.
Thank you.
Very Respectfully,
(b)(6)
I
-~)
Work: 619-556-3802 ext. 41 01/41 03
SIGNATURES
(b)(6)
Signature of Provider; j Date of Signature: 8/16/2010
Contact In
of Session:
Notes:
Group Note/Participation Form
(b)(6)
1ent's Name:
(b)(6)
Manager: :
Group Name: FA! CON
Group Leader(s)· (b)(6)
Session# 22
Content of C~roup:
Group described their initial courtship with partners and changes that led to domestic
~~~1ore precisely, individuals differentiated betvJeen phases m thetr relationships and
rule changes" whereby verbal abuse and then physical abuse was ultrrnately accepted and
tolerated. Group participated as a whole and each was called upon to read chapter
matenal and contribute to dry erase board exercise.
Confident
Regretful
Other: apathy X
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Cornrnents or Closing Summary:
Client participates when called upon but presents as apathetic and unmotivated.
confronted he offers a bright smile and then contributes but only the rnost minima!
often says ''I don't know" as if confused but it appears to be evasive and garney.
complicating diagnostic impressions and progress if any Case
created client before done with
External Military:
http:< tlsm1s.c nic. na\ y .mi 1/componcnts!l\.mmJ( :lmicuiContactNot,;Rcport .asD.'I')A nnl icmiu... I 7:2 0 l l
ntact Note
(b)(6)
of Session:
(b)(6)
Manager· (b)(G)
Name· FALCON
Leader(s): (b)(6)
# 23
of Group:
rev1ewed Interpersonal confltct this week, either in current romanttc relationship or
Skills used vvere identified by client and peers with open discusston of
In-group assignment was written and collected to improve compliance and
accountability. Group was also designed to build towards upcoming weeks 'Nhere
client progress reports w1ll be made (through client self-assessment).
no motivatton x
Regretful
Other-apathetic x
/;,dditional Comments or Closing Summary:
hups: lfsmi ::;.en ic. na\ :v .mil/componcntsil(_>nns Clinical('ontact\JotcRcport.aso;-..;? Annlicat io.. 1 ·7 ''0 11
[Client continues to participate only when called upon and does the absolute minimum for
[group. For example. he only contributes when threatened with consequences, i.e .. homework
tcompleted or no-credit for group Boundaries are set and client complies but is routinely
1 unmotivated and acts as if he can not hear facilitators, yet seems to hear well ~vvhen
Jtalking wrth peers.
'
(b)(6)
Contact:
rv of Contact:
(b)(6)
IS to confirm that you, (b)(G) OOB· 06 October 1987, contacted the Navy
Advocacy Program on 29 July 2009 1n reference to your mvolvement 1n an alleged
violence incident
, you have participated in the Family Advocacy Educational Session of 3 5 hours and
a requirement prior to offender group treatment. You have also completed 22 sessions of
group treatment which meets weekly from 1330-1500 Case management services
ongomg contact \Nith the victim and your command.
vour case manaqer, I am the point of contact for your case. My contact information is:
(b)(G) at 619-805-5800; Fax 619-556-9473 or email:
(b)(6)
(b)(6)
Manager
and Family Support Center, Village of Serra Mesa
141 Mton f~oad
01ego, CA 92123
19) 805-5800
(b)(6)
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li tc I Contact Note
(b)(6)
of Contact: In Person
of Session: G
Name: (b)(G)
lv1anager (b)(G)
Name. FALCON
Leader(s) (b)(6)
Session# 24
Content of Group
Cl1ents described progress made in particular, changes in how they report their part in the
violence incident that resulted in this group. lndtviduals were charged with
identifying the use of "minimization, denial, and rationalizing." Peers were encouraged to
one another as well.
THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
rded x Suicidality
l=<esentful Increased Risk of Re-abuse
Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
lnapproprtate Other: poor/limited mottvation for change x
x None
Confident
Regretful
apathy x
Comments or Clostng Summary:
demonstrated some reaction to confrontation by peers that his passive approach to
problem solving results in blaming others, helplessness, and ultimately greater frustration
Cl1ent appears to have gained little from group but his overall respect for therapists and peers
improved, i e , bnnging h1s book, homework. and not picking at his nails during group
(b)(6)
http~,:- rr'>m is.cmc:.. navy .111 IJ, components. J(mlls/CI inica !Contact Note Rcnorl.asnx •) ·'\ nnl ic;ll i!1
linical Contact Note
(b)(6)
92280 Client Name:
(b)(6)
10/14/2010
(b)(6)
Counselor/Case Manager
at Serra Mesa Branch FFSC
14·1 .Afton Road
Die~JO. CA. 92123
19) 805-5800
619/556-1277. FAX: 858-87 4-0665
(b)(G) Facebook \N\NW.Facebook.com/FFCPSanDiegc (b)(G)
(b)(6)
(b)(6)
Signature: 10/14/2010
ntact Note
(b)(6)
of Contact: Phone
of Session: G
10/21/10
(b)(6)
Clients f\lame:
Manager: (b)(G)
Group Name FAI CON
(b)(6)
Group Leader(s):
Session#
Content of Group Chapter 1 & 2
reviewed chapter test and homework addressing 'skills" learned from previous groups.
In paliicular, individuals were challenged to describe changes since starting. This modified
self-assessment of progress was designed to promote introspection and allow peers to
as wanted, continued use of defenses against assuming personal responsib1l1ty for
. Clients articulated changes in perception since starting group.
THERAPEUTIC CONCERNS
Upbeat lncrdent of Re-abuse
Guarded x Suicidality
!Increased Risk of Re-abuse
Calm x Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
Inappropriate Other:
None
(b)(6)
re of Provider: (b)(6)
ofSignature: 10/28/2010
In Person
of Session:
Date: 71'1/iO
Client's Name (b)( 6 )
Manager: (b)(G)
THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded Suicidality
Resentful Increased Risk of Re-abuse
Hostile, Aggressive Behavior
F1·ustrated Increased Depression
Rel'lect1ve Increased Stress
Inappropriate
Flat x None
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Contact In Person
of Session:
Notes:
Group Note/Participation Form
loate: 7/15/2010
!Client's Name: (b)(G)
~ ·1
li 1v anager:
(b)(6)
ISession # 20
Icontent of Group. Reviewed use of choices skills as they apply to current relationships.
/Asked clients to use "Choices" language to identify skills. Reviewed the 3 bandits, blaming,
!hurting, and bossing, and elicited examples regarding partner's most prominent style Will
1 rev1sit next week as clients ident1fy their own style and how they irnagine it impacts their
/' partner or other significant current relationships Homework assigned and clients will be held
1
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disinterested in the materials and his overall motivation to make change appears to be
mm!mal to nonexistent. He minimized the extent of the original incident, and consistently
externalized blame for failures 1n his life He appears apathetic about treatment-nonetheless
1
group facilitators are attempting to better assess v1a greater verbal and vvritten participation
1 client.
I (b)(6)
(b)(6)
Date of Signature: 7/16/2010
Session Notes:
Group Note/Participation Form
Session Notes:
Group Note/Participation Form
6
Date: 11/19/09 Client's Name:' (bl( 6 l Case Manager: (b)( l
Group Name: FALCON Group Leader(s): (b) (t.o)
Session# 2
Session Notes:
Group Note/Participation Form
Content of Group:
(1 =none: 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 2
Personal Disclosures 3
Empathy for child and/or others 2
Knowledge & Understanding of
Anger Management Strategies 3
Motivation for Change 3
Insight & Self Awareness into
Behavior 2
Respectful attitude 5
Overall Participation 3_
(b)(6) (b)(6)
This is and I am emailing you in regards to We are
(b)(6)
scheduled to get underway tomorrow Jan 20th and will not be able to attend
his class this week. So if you will please excuse him from class so he we can keep our
operational commitment. Thank you and if our schedule changes any l'lllet you know. If you
need to talk about this you can email me back and let me know and I will call. Thanks again.
V/R
(b)(6)
SIGNATURES
Signature of Provider: IDate of Signature: 1/19/2010
Session Notes:
Group Note/Participation Form
Content of Group:
(1 =none: 2=rarely;3=sometimes;4:::often;5=very often)
Acceptance Of Responsibility 2
Personal Disclosures 2
Empathy for child and/or others 2
Knowledge & Understanding of
Anger Management Strategies 2
Motivation for Change 3
Insight & Self Awareness into
Behavior 2
Respectful attitude 5
Overall Participation 2+
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Clinical Contact Note
Case Number 92280 Client Name: (b)(6)
Session Notes:
Group Note/Participation Form
Content of Group:
(1 =none; 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 2
Personal Disclosures 2
Empathy for child and/or others 2
Knowledge & Understanding of
Anger Management Strategies 2
Motivation for Change 2+
Insight & Self Awareness into
Behavior 2
Respectful attitude 5
Overall Participation 2+
AFFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded Suicidality
Resentful Increased Risk of Re-abuse
Calm x Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
Inappropriate Other_ _ _ _ _ _ _ __
Flat None
Angry
Sad
Anxious
Confident
Regretful
Other
Additional Comments or Closing Summary:
6
(b)( ) said that thinqs are going ok for him; he is working long hours and is often tired, but
6
he likes his job. (b)( ) Nas quiet during group exercise/discussion of self-talk and cognitive
factors that escalate feelings of anger. He appears to struggle to stay awake and was
directed by group facilitator to stand up or make some effort to stay awake during group.
6
(b)( ) then remained alert for the duration of the group, although he did not volunteer
!comments or feedback to other group members. (b)( 6 ) demonstrates minimal grasp of
(b)(6)
I am Division Officer aboard USS KIDD (DOG 100) here on 32nd
Street Naval Station San Diego. It has been brought to my attention that I am to inform you
that our ship will be at sea for the period of 4 February 2010, thus (b)(6) will be unable
to attend his scheduled appointment. If there are any questions or 1t this 1s not a satisfactory
method of informing you, please let me know. Thank you.
Very Respectfully,
(b)(6)
' ~) [lP)
- --
SIGNATURES
Signature of Provider: (b)(6)
IDate of Signature: 2/4/2010
Content of Group:
(1 ==none: 2==rarely;3==sometimes;4==often;5==very often)
Acceptance Of Responsibility 2
Personal Disclosures 2
Empathy for child and/or others 2
Knowledge & Understanding of
Anger Management Strategies 2
Motivation for Change 2
Insight & Self Awareness into
Behavior 2
Respectful attitude 4
Overall Participation 2
AFFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded Suicidality
Resentful Increased Risk of Re-abuse
Calm x Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
Inappropriate Other_ _ _ _ _ _ _ __
Flat None
Angry
Sad
Anxious
Confident
Regretful
Other
Additional Comments or Closing Summary:
6
(b)( ) said that things are going ok for him. He participated in group introduction exercise
6
(2 new members today). (b)( l was quiet during group exercise/discussion of taking
responsibility for anger, and offered no input of any kind. He appeared to struggle to stay
awake and left the room briefly, then returned and was more alert for the rest of the group.
Session Notes:
Group Note/Participation Form
Content of Group:
(1 =none; 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 2
Personal Disclosures 2
Empathy for child and/or others 2
Knowledge & Understanding of
Anger Management Strategies 2
Motivation for Change 2
Insight & Self Awareness into
Behavior 2
Respectful attitude 4
Overall Participation 2
AFFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded Suicidality
Resentful Increased Risk of Re-abuse
Calm X Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
Inappropriate Other_ _ _ _ _ _ __
Flat X None X
Angry
Sad
Anxious
Confident
Regretful
Other
Additional Comments or Closing Summary:
(b)(B) said that things are going ok for him. He passively participated in. (b)( 6 l was quiet
throughout group.
The group focused on Thoughts and Behaviors: Responsibility, Violence, and Control
Chapter. He limitedly participated during the group discussion. When asked to repeat a
concept that had just been discussed he did not know what the group had been talking about.
Session Notes:
Group Note/Participation Form
6
Date: 2/25/10 Client's Name: {b)( ) Case Manager: (b){ 6 )
Content of Group:
(1 =none; 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 2
Personal Disclosures 2
Empathy for child and/or others 2
Knowledge & Understanding of
Anger Management Strategies 2
Motivation for Change 2
Insight & Self Awareness into
Behavior 2
Respectful attitude 4
Overall Participation 2
AFFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded Suicidality
Resentful Increased Risk of Re-abuse
Calm X Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
Inappropriate Other_ _ _ _ _ _ _ __
Flat X None X
Angry
Sad
Anxious
Confident
Regretful
Other
Additional Comments or Closing Summary:
6
(b)( l participated in group introduction exercise to welcome new member. He said thinas
were going ok for him and nothing was new. He is not in a relationship at this time. {bl{ 6 l
was quiet and did not actively participate in group exercise/discussion about power and
control in relationships.
https :1/ffsm is. en ic. navy .m i1/components/forms/Cl inicaiContactN oteRenort.asnx'/ Ann Ii r.Rr in 1 /7 1 /() 1 1
i ae,c: I Ul ./..
Session Notes:
Group Note/Participation Form
Content of Group:
(1 =none; 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 2 Motivation for Change 2
Personal Di~closures 2 Insight & Self Awareness into
Behavior 2
Empathy for child and/or others 2 Respectful attitude 4
Knowledge & Understanding of
Anger Management Strategies 2 Overall Participation 2
(b)(6)
lam (b)(6)
Division Officer aboard ' J~)&) here on 32nd
(b)(6)
Street Naval Station San Diego. Our ship is currently at sea and will not be
able to attend this week's course.
Please let me know if you have any questions.
Thank you.
Very Respectfully,
(b)(6)
(b)[~) - -·
SIGNATURES
Signature of Provider: (b)(6)
IDate of Signature: 3/18/201 0
Summarv of Contact:
Dear (b)(B)
The CRC actually recommended that (b)(B) complete 8 sessions of Men's Group
and the SM has completed and fulfilled the recommendations of CRC. Based on that fact the
case could be closed. However, since the civilian court was ordering him to 52 weeks of
Men's Group, the SM asked if he could complete the entire 26 week FAP Program. We were
willing to accommodate his request, as the groups out in town cost $25 to $40 per week.
We provided (b)(B) with a letter to the court asking that he be allowed to complete
the 26 week program at FAP and they agreed.
Let me know if you would like me to keep the case open to accommodate his civilian
obligations.
Sincerely,
(b)(6)
(b)(6)
I'll be speaking with our XO and CMC regarding this Monday and will brief you on the
outcome. In the mean time he will attend his next meeting.
r<tgt: 1 01 ·'
Summary of Contact:
Dear (b)( 6 l
If he and command decides that they would like the case to closed within the military system,
then I can move forward and close the case based on his completion of the 8 recommended
sessions. The fact remains that he would still need 44 sessions to complete court obligation
and those would be costly.
Sincerely,
(b)(6)
-----OriainAI MA~!'::Rm=•-----
From: (b)(6J
(b)(6)
If you feel he has completed what is required and he has benefited from the training, I would
What are the consequences looking like on your end at this point?
Very Respectfully,
(b)(6)
-----Oriqinal Messaqe-----
From (b)(6)
Dear (bl( 6 l
6
l missed his FAP group again today. In fact, he has not been here since 25 Feb
(b)(
2010. I would appreciate an update on his status.
Thank you,
(b)(6)
SIGNATURES
Signature of Provider: (b)(6)
IDate of Signature: 4/5/2010
t. . H.,.....,,/f-(.;·.r,., •....-.:,. .-..-.. :r- ...,.,,,.,, _...:l/..-.,....-- ...... ----"-~1-C~ ..... ---'r A nf'\1:._~ __ 1 ) . . 1 - , - n
1 rt..J \.._...lllll\....al '---..-Ullla\.-t. l'IUlC
like for him to get on with his life. Thank you for your help. Please advise.
Very Respectfully,
(b)(6)
----Orioinal Messaae----
(b)(6)
From:
Sent: Monday, Apnl 05, 2010 8:48AM
To: (b)(6l
(b)(6)
Subject: RE: Continued Group Absence-
Dear (b)( 6 l
Let me know if you would like me to keep the case open to accommodate his civilian
obligations.
Sincerely,
(b)(6)
(b)(6)
I'll be speaking with our XO and CMC regarding this Monday and will brief you on the
outcome. In the mean time he will attend his next meeting.
What are the consequences looking like on your end at this point?
VP.rv RP.~nAr.tftlllv
(b)(6)
I (B)L<o} ' .
Work: 619-556-3802 ext. 4101/4103
Dear (b)(e)
(bl( 6 l
missed his FAP group again today. In fact, he has not been here since 25 Feb
2010. I would appreciate an update on his status.
Thank you,
(b)(6)
SIGNATURES
Signature of Provider: (b)(6)
IDate of Signature: 4/5/2010
Clinical Contact Note
(b)(6)
Case Number 92280 Client Name:
Contact Date: 4/15/2010
Time Spent: 1.5 jType of Contact: In Person
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group !Type of Session: Group
Session Notes:
Group Note/Participation Form
Content of Group:
(1 =none; 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 2
Personal Disclosures 2
Empathy for child and/or others 2
Knowledge & Understanding of
Anger Management Strategies 2
Motivation for Change 2
Insight & Self Awareness into
Behavior 2
Respectful attitude 3
Overall Participation 2
AFFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded Suicidality
Resentful Increased Risk of Re-abuse
Calm X Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
Inappropriate Other_ _ _ _ _ _ __
Flat X None X
Angry
Sad
Anxious
Confident
Regretful
Other
Additional Comments or Closing Summary:
6
(b)( ) participated in group introduction exercise to welcome 2 new members. (b)(S)
was quiet and did not actively participate in group exercise/discussion about positive self talk.
- - - - - - - - -(b)(6)
------------
j(Kevlsed 7/2006 MB)
Clinical Contact Note
(b)(6)
Case Number 92280 Client Name:
Contact Date: 4/22/2010
Time Spent: 1.5 !Type of Contact: In Person
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group !Type of Session: Group
Session Notes:
Group Note/Participation Form
(b)(6)
• If'
\._...-IIIIIL.(ll \._.,\.1Ullt"\l,.,...llJlE LVJllUVl l"iVt\...
Session Notes:
Group Note/Participation Form
Date 6/3/10
Client's Name: (b)( 6 )
Case Manager: (b)(6)
Group Name: FALCON
Group Leader(s): (b)(6)
Session# _16_
Content of Group: Group began with short check in. Group reviewed homework assignments
from Chapter 9 of Choices Curriculum. Group discussed Chapter 9 as there were attendees
at group that had not been present the week prior. Group discussed concepts of "hurt, blame,
and bossy" being identified "escalators" of conflict. Group then went on to discuss homework
assignment involving asking spouse to identify if husband engages in any of these behaviors
during conflict. Group was to then request that spouse assist in modifying these behaviors.
noticeable increase in participation and is attempting to apply information despite not having a
6
current relationship. (b)( ) will occasionally share oersonal information but rarely
6
speculates on the other group members information. Cb)( ) demonstrated an adequate
understanding of homework information but would appear to benefit more from individual
discussion due to shyness.
(b)(6)
(b)(6)
6
In your note you indicated that (b)( l might benefit from individual. Your note also
indicates that he was at Week 16 in treatment. Since he was Substantiated some time ago,
he was actually only recommended by CRC to do 16 weeks. However, he was ordered by the
court to do 52 week. That means that he can chose to complete 26 weekswith FAP which the
court will count towards his 52 week requirement. However, if he and command chose he can
be considered complete since he fulfilled the CRC treatment required. If he goes out into the
community, he has to pay for each session. Command hoped to avoid putting him in this
financial position. I can talk with the SM, or you are welcome to address these options with
him,
Sincerely,
(b)(6)
SIGNATURES
Signature of Provider: (b)(6)
JDate of Signature: 6/9/2010
Clinical Contact Note
(b)(6)
Case Number 92280 Client Name:
Contact Date: 6/17/2010
Time Spent: 1.5 jType of Contact: In Person
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group jType of Session: Group
Session Notes:
Group Note/Participation Form
Date: 6/10/1 0
Client's Name: (b)(6)
Case Manager: (b)(6)
Group Name: FALCON
Group Leader(s): (b)(G)
Session # 17_ __
Content of Group: Group began with check in and brief initial incident details. Group covered
Chapter 10 material in CHOICES program. This material included review of "The Box". The
group then discussed ways in which conflict escalates and ways to avoid escalation. Step one
was identified and discussed by group members including the necessity to identify the core
problem. Group engaged in dramatic role play to illustrate identification of core problems
during marital discord.
I spoke with (b)(6) on 18 June and he indicates that he wishes to continue in group until be
completes the 26 week curriculum.
Sincerely,
(b)(6)
tlt'H.''.r/ff-Cn""l;C' r-n;ro n r n ' ' ' -n""';I/ ..... ,....,.., .............................. ~L'/1'......... ~--··'r 1\ Df"'l: .• : .ll.T • n
r·r\r \.._.!Jllll..c.U \....-Ul!LaL>t J'fUtc:
Summary of Contact:
(b)(6)
From: (b)( 6 )
Good Morning,
Please be advised that the following clients were not in attendance at FALCON group on
6/17/10. Please advise as to whether these absences are excused.
{b)(6)
V/R
(b)(6)
(b)(6)
FOR OFFICIAL USE ONLY, PRIVACY ACT NOTICE: This electronic transmission may
contain privileged or other official information intended only for the person(s) named above. It
may be protected from disclosure by applicable law, including the Privacy Act, attorney-client
privilege or work product doctrine. Any use, distribution, copying or disclosure by another
Clinical Contact Note
Case Number 92280 Client Name: (b)(6)
Session Notes:
Group Note/Participation Form
Date: 6/24/10
(b)(6)
Client's Name:
Case Manager: (b)( 6 )
Group Name: FALCON
Group Leader(s): (b)(6)
Session # _18 _ _
Content of Group: Group performed cursory check in regarding relationships with spouses
and children. Group then began process of reviewing homework from Chapter 10. Group
discussed application of previously covered six steps to resolving conflict. Group discussed
details of homework and problems experienced when implementing homework. Group
processed departure of clinician 1 ~~~)
External Military:
(b)(6)
of Signature: 6/25/2010
of Contact: In Person
Of Responsibility 3
D1sclosures 3
for child andlor others 3
& Understanding of
Anger Management Strategies 3
for Change 3
& Self r~wareness into BnhJVIOr 3
sttitude -1
THERAPEUTIC CONCERNS
Su1cidal
Increased Risk of Re-dtJuse
x Hostile. Aggressive Boh8v1or
Increased Depression
x Increased Stress
Comments or Clos1ng Summary Client had re3d this week's chaptm and was prepared for the d1scussion. Client
act1ve talkin~J ~1bout how he maintams clear [)Oundaries in h1s relationsl11p With farn1IV nnd friends, which makes him
to ever cross the Ime of ve·rbal abuse. Client was also very open and supportive with <motller group member \:Vhn
[() lee! that •mrbal domlnEJnce in a could be
1-~q----·-···-····
·(fsmi s.cn i c .navy nti !/components/ forms 1PnntA Ilr onns.aspx 12112/20 I 0
Page 12 of 46
I
·£ ession # 5
IA ceptance Of Responsibility 3
I~ ersonal Disclosures 3
IE rnpath)' for child and/or others 2
IKrowledge & Understanding of
~~ective Anger Management Strategies
3
Irv otivation for Change 3
lr sight & Self Awareness into
B havior
3
R ~spectful attitude 4
Overall Participation 4
Ad~itional Comments or Closing Summary: Client talked about his feelings regarding men showing emotion Client shared
' "t: .og cy he WO' with his to thee who sobbed d"'log his g"odmothec' duoe"l Cileot tell tho! his fothoc set a pooc e<omple
for the other men in the family. However, client did state that he found himself crying when a good friend died unexpectedly
He shared that he wondered if the loss of his friend brought on the emotions he had not shared about the loss of his
grcrdmother.
PI~ n Status ··..:· :'/1) "':~, ~:i' I ' ,y '- PitT~ "·'·' .:z; . :...:·!!!',-' ! ~~ r·) :~i 1 i
of Signature: 8/17/2010
'
Date: 11/18/10
' Client's Name (b)(6) Case Manager: (b)(6)
• Group: 3
• Group Leaders: (e,) (CP)
Content of Group: Chap. 9: Homework; Chapter 10: Problem Solving Steps
IF Jan Status . ·rr r;tF ·;,· ':-~ -. ~;; ; F~a' /--'1{-r(.- ) r ~(<;?tP:;_'<''d F'·;.·n
jecommended Referrals:
It -House FFSC;
F~P
I External Military: !External Civilian: ITrf-Care:
i>IGNATURES
S gnature of Provider: (b)(6) l Date of Signature: 11/19/2010
htfs:l/ffsmJs.cnic.navy.n1lllcomponcnts/forms/PnntAllFom1s.aspx 121221201 n
Page 3 of30
Date: 28 Oct 10
Client's Name: (b)(6) Case Manager:(b)(B)
Group Name: OAK Group Leader(s): t_B)( 1..)
. Session# 1
Content of Group: Chapter 9 - Solve Your Problems
(1 =none; 2=rarely; 3=somelimes; 4=often; 5=very often)
1 2 3 4 5 N/A
, Acceptance Of Responsibility 2
Personal Disclosures 2
Empathy for child and/or others 2
• Knowledge & Understanding of
• Effective Parenting Strategies n/a
Motivation for Change 2
· Insight & Self Awareness into
Behavior 2
Respectful attitude 3
bverall Participation 2
ecommended Referrals:
l -House FFSC:
1FAP
IExternal Military: !External Civilian: ITri-Care:
. ~IGNATURES
f ignature of Provider: (b)(6) IDate of Signature: 11/812010
ht1ps://ffsmis.cnic.navy.mil/components/fonns/PrintAilFonns.aspx J 2/??1?01 n
Page 4 of30
''·
Ciagnostic Impression . '. 'f';,.··' C\'-._·',!1,;.. (.·~
.f ecommended Referrals:
l -House FFSC:
Ff\P
IExternal Military: !External Civilian: ITri-Care:
~IGNATURES
~ ignature of Provider: (b)(6) ) Date of Signature: 11/912010
htrs ://ffsm is. cmc .navy. rmllcom ponents/ forms/Pri ntA I!Fonm.aspx 12/22/20 I 0
l
t'age :~ o l 30
Collateral Contact:
Summary of Contact: r. 1 ,
Client calls to arrange group. He will start OAK on 28 OCT 2010. L.b j{lP) stated he could come at regular time, 1330.
SIGNATURES
: Signature of Provider: (b)(6) Date of Signature: 10/25/2010
JJf'r
1 .l ..0.~ 1 ~ .i .l J I J. ....... ! j_ l.IU Page 6 of30
I
Collateral Contact:
Summary of Contact:
Client seen in individual intake. He clarified that he is not in DVRP, and gave court paperwork explaining that he was
ssigned to 52-weeks of individual counseling. He has completed 11 sessions of that, and the court agreed to counting the
AP 26-wk Men's Group against the 52. Client stated that CPS 1s now doing background checks on his aunt in Las Vegas,
nd on his sister in Delano. CA, to see if the child can be placed with either one of them. He arrived in a Taxi, as his vehicle
~as imontmn<>tj at the border when his wife was arrested. He was pleasant, cooperative, and wants to start group. Email sent
~h~ )_
1 to request afternoon group. .
SIGNATURES
Signature of Provider (b)(6) Date of Signature: 10/8/2010
-----Oriainal Messr~nA-----
From: (b)(B) NAVBASE San Diego, N21
· Sent: luesdav. SAniAmhAr ?R ?Q10 15:30
To (b)(6) ~NRSW, N91
SuG1ts(;t. r1t:. I..:Jroup uuesuon
~hanks. This is a very difficult and complicated case, and I haven't had it from the beginning. I am going to assumE! that
(b)(B) got put on your list automatically from the CRC, If that is the case, please take him off of your list, because he is in
rhe 52-week court-ordered program after being convicted of serious DV He will eventually need Khulani, but not Cypress.
----Qrioinal MRSS::10A-----
rom: (b)(B) CNRSW, N91
pent· 1 IIA"ri"'" ""'ntcnnber 28, 2010 14:48
o: (b)( 6 ) NAVBASE San Diego, N21
pc: 1 (b)(6) CIV NAVBASE San Diego, NOO
ubjecr: Kl::: Group Question
1
. (b)(B) sorry for the misspelling your name. I'm co-facilitating with
month ago (b)(6)
(b)(6) in the Cypress group. I took (b)( 6 ) place abou
- --OrininAI MA~""'"''-----
From: (b)(B) NAVBASE San Diego, N21
~ent: ·I ueso::~v SP.niAmrv>r ?A 2010 ·t3:46
o: (b)(B) CNRSW, N91
EubJeCt: t-w: Group Question
. :>IGNATURES
Signature of Provider (b)(6) J Date of Signature: 9/28/201 0
ht tJs:/1 ffsmis. en ic. navy .111 iIIcomponen tsl fom1sl Prin tAl IForms. aspx ]21221)[) 1()
I
Page 11 of 30
CONTACT
Contact Name: (b)(B)
Collateral Contact: GOVERNMENT
AGENCY/ORGANIZATION
IType of Contact: Email
Contact Notes:
From: (b)(B) CNRSW, N91
"To (b)(6) NSWC Corona, FT24
Sent: 1 ue Sep 28 15:48:00 2010
Subject:
Hi (b)(6) I am trying to see if you are the CM for a fellow in our DV aroup. He is name is (b)(6) and we haven't seen
him yet. Could you let me know if he is one of yours. Thanks (b)(6)
(b)(6)
pin,cal Counselor
~avy Region Southwest
leet and Family Counseling Services
135 Dolphin Alley Bldg 261
:ian Diego, California 92136-5185
hone 619 556-8816
ax 619 556-9473
SIGNATURES
ignature of Provider: (b)(6) IDate of Signature: 9/28/2010
of Contact:
of Session:
, ssion Notes:
(Group Note/Participation Form
(b)(6)
~ate: 9 Dec 09 Client's Name: Manage1 (b)(e)
ifession # 15
Content of Group: Review of "The box" and relapse prevention
~cceptance Of Responsibility 3
!Personal Disclosures 3
!Empathy for child and/or others 3
~nowledge & Understanding of
S:ffective Anger Management Strategies
~
r$11otivation for Change 3
lpsight & Self Awareness into
~ehavior
r~espectful attitude 4
0verall Participation 3
https: / iffsm i s_cnic. navy _m i !/com p1menls/ form s/Prin tAl 1Form s_aspx l 17<20 I I
Comments or Closing Summary:
was attentive and participated a little. He will complete this group next week.
gave some feedback to those graduating when they shared their relapse prevention
h!1ps: . 1fl'sm is. en ic. navy .mi !;com poncnts/forms.'PrintAJ Jl:orms.aspx ]/7/201 J
finical Contact Note
(b)(6)
of Contact:
of Session:
Notes:
Note/Participation Form
(b)(6) Manager:
9 Dec 09 Client's Name: (b)(G)
(b)(6)
Cypress Group Leader(s)·
Respectful attitude 4
Overall Participation 3
:.· ·ffsm is. c nic .mn'.Y. mil/com po nen ts/ l(xms/Pri ntA ll Forms.aspx 1/7/20 ll
Comments or Closing Summary:
was attentive and participated a little. He will complete this group next week.
gave sorne feedback to those graduating when they shared their relapse prevention
(b)(6)
of Signature: 12/10/2009
of Supervisor: (b)( 6 ) Date of Signature: 12/14/2009
of Contact:
of Session:
Session Notes:
(b)(6)
Date: Sep 30, 09 Client's Name: Manager: (b)(6)
(b)(6)
Group Name: Cypress Group Leaden's):
Session# 12
Of Responsibility 3
Personal Disclosures 3
Empathy for child and/or others 3
Knowledge & Understanding of
Effective Anger Management Strategies
3
Motivatton for Change 3
lnstght & Self Awareness into
Behavior
3
Respectful attitude 4
Overall Participation 3
Anx1ous
confident
1Regretful
I
Other
(b)(6)
Signature of Supervisor:
of Contact:
of Session:
(b)(6)
Group Narne: Cypress Group Leader(s):
I
Sess1on # 11
Acceptance Of Responsibility 3
Personal Disclosures 3
Empathy for child and/or others 3
1\nowledge & Understanding of
E:ffective Anger iv1anagement Strategies
1'-·f
~?lotivation for Change 3
Insight & Self Awareness into
Beflavior
Anxious
Confident
Regretful
O·!her
(b)(6)
of Signature: 9/4/2009
(b)(6)
of Supervisor: of Signature: 12i8/2009
of Contact:
of Session:
Notes:
Group Note/Participation Form
(b)(6) Manager: (b)( 6 )
Date: ,L\ug 12, 09 Client's Name:
(b)(6)
Name: Cypress Group Leader(s):
#iO
Anxious
Confident x
F~egretful
Other
li I Contact Note
Number 60118 Client Name: (b)(6)
of Contact:
of Session:
Notes:
Group Note/Participation Form
(b)(6) (b)(6)
5 ;\ug 09 Client's Name: Case Manager:
Session# 9
Jl,cceptance Of Responsibility 3+
Personal Disclosures 4
Empathy for child and/or others 3
Knowledge & Understanding of
Effective Anger Management Strateg1es
3
Motivation for Change 3+
Insight & Self Awareness into
Behavior
3
Respectful attitude 4
Participation 4
External Civilian:
of Contact:
of Session:
Notes:
Note/Participation Form
of Group·
on recognizing & setting boundaries with others using "I statements" as well
as recognizing & accepting their partner's differences.
.Acceptance Of Responsibility 3
Personal Disclosures 3
Empathy for child and/or others 2
~<nowledge & Understanding of
Effective Anger Management Strategies
'3
Motivation for Change 3
!nstght & Self Awareness into
!Behavior
E<espectful attitude 4
Overall Participation 4
THERAPEUTIC CONCERNS
LJpbeat xxx Incident of Re-abuse
C~uarded Suicidality
l=i:esentfullncreased Risk of Re-abuse
Calm x Hostile, Aggressive Behavior
Frustrated Increased Depression
f1:eflective Increased Stress
1t:1appropriate Other _________
F'lat None x
Jl,nxious
j Confident x
Regretful
Other
(b)(6)
Signature: 7/31/2009
ht lps:: ffsm i s.cnic .navy .mi Lcomponcnts 1 form:::,/PrintA Ill :urms.aspx lf7i2()l1
li I C ntact Note
(b)(6)
Number 60118 Client Name:
of Contact:
of Session:
(b)(6) (b)(6)
: 17 June 09 Client's Name· Case manager:
Session# 7
Confident
Regr·etful
Other
of Contact In Person
of Session: Individual
Notes:
completed his second make-up session for Men's DV Group. Focus of today's session
on relationships and "buitding of equity" in a relationship to include long range goals.
family life. and child development ADM continues motivated and interest in personal grmvth
voices appreciation for what he learns and is looking forward to including what he is
in his re!ationsh welL Interested motivated and
(b)(6)
of Signature: 6/1212009
(b)(6)
jproup Name: Cypress Group Leader(s).
!t
/Session# 15
i!
li
Content of Group: Review of "The box" and relapse prevention
1
<f1 =none, 2=rarei'y'; 3=sometimes; 4=often, 5=very often)
l·~cceptance Of Responsibility 3
1
1fersonal Disclosures 3
ll~mpathy for child and/or others 3
jt~nowledge & Understanding of
$.• ffective Anger Management Strategies
!=~
/lv{1otivat1on for Change 3
lipsight_ & Self /\ware ness into
E?ehavJor
3
IF~espectful
II<~verall
attitude 4
Participation 3
I
/tiFFECT THERAPEUTIC CONCERNS
J dpbeat xxx Incident of Re-abuse
1
quarded Suicidal
1Rjesentful Increased R1sk of Re-abuse
1
lc!airn x Hostile, Aggressive Behavior
I Frustrated Increased Depression
!Reflect1ve x Increased Stress
/lrjappropriate Other__________
1F!at None x
I ,,;_,gr'
l''""'ll j
1Sad
i "-: .
ik':JXIOUS
IC.bnfiden t
!Regretful
/Olher
1
lClient vvas attentive and participated a little. He \Nil! complete group next week.
i~dditlonal Comments or Closing Summary:
ttliS
!Client ga·.;e some feedback to those graduating when they shared their relapse prevent1on
!Plan
~-- ------- ------ ---------------------------------------
:Plan Status · ' . , , ' ' ;
lbi~g~~stic lr;p-ression -----------·
iR~~ornme~-d~d-Referr~!s: ----~-----
1-,·------.
!In-House FFSC: jExternal Military: !External Civilian: jTri-Care:
>'
il
u,') _________________________
.~
, t>eSS/0/i 'fF 15
~~cceptance Of Responsibility 3
fPersonal Otsclosures 3
$mpathy for child and/or others 3
f~nowledge & Understanding of
t~ffective J\nger Management Strategies
3
~Activation for Change 3
lj,sight & Self Awareness into
IE3ehavior
I :,
~~~espectfu/attitude 4
ldverall Participation 3
I 1
j J
Icbntident
J.,grp•f, 11
Ii R . .,_ ~ lil
iOiher
i ~
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1
/20 II
~Add1t1onal Comments or Closing Summary
!Client 'Nas attentive and participated a little He \Nill complete this group next week.
!CI1ent gave some feedback to those graduating when they shared their relapse prevent1on
ilplan
!fP-~~~--S-tcrt~-~~c--.·-~~ ----------_. ·--c-· -~- ~-----·------~---~---------------i
------------~---------------···!
,'!Diagnostic
1-~-------------
Impression ( (· . _
------'---------------------------------------------··-
it~e~_?_r::mended Referrals:
l)n-House FFSC: !External Military: !External Civilian: ITri-Care:
li i T
--------~
ltsig~atl~~~ of Provider:
.
(b)(6)
__ ---~Date of Signature:_~~2?12009
IE3ign;ture of Supervi_s_o-r:-
';------·-----· ·---
(b)(
6
l Date of Signature: 12/14/2009 ']
1
~
l /7 20 j 1
Clinical Contact Note
(b)(6)
Case Number 60118 Client Name:
Contact Date: 10/1/2009
-----------------
!i_f!i~- -~p_e_r:!:__Q _____ _
Numbe-r of Individuals Seen: 0
Type of Counseling Group: !Type of Session:
_j __
! •
1
Sesslon Notes:
l
I
Date: Sep 30, 09 Client's Name:
(b)(G)
I Sess1on # 12
!.Regretful
:Other
10
t•
!T-;m is. cnic .navy. m i I,. compnllc'l1l:ii furms Pn n L\tl Forms ::tspx l 7'20ll
jClienl was very reserved this week. He was attentive; but dtd not participate much as 2 nevv
lmernbers did most of the talking
~P la-r: St;t~s r·
··-----·---·-·---·----
~Qi~~gnostic Impression c·
!'Recommended Referrals:
!In-House FFSC: !External Military: !External Civilian: !Tri-Care:
!:__~-~---------·
I! Signature of Provider: (b)(6) --·--· TO ate of ·signature: 1Oi 112 009
'1'-·- - - - - - - - - - · · · - - - -
[;_'S_i_g_r~~~~-ro_of_S_u_p_er:!_i_so_r_:
(b)(6)
Date of Signature: 12/8/2009
·---L- ----------·-
'
i ·~. CI1JC na·v·y .rn 1i/ co Ill poncn [:;.' l'orn 1s/Pri 11 r.-\ II r·orms aspx I 7 ~()! I
finical Contact Note
(b)(6)
ase Number 60118 Client Name:
!Contact Date: 914!2009
1:---··---~-------------·------ ---~- ..- - - - - -~-----------
~Time Spent: 0
11--·-----------·----....- -..._____________________ ___,!Type of Contact:- - - - -·---·-------
iiNumber of Individuals Seen: 0 I
lrrype of Counseling Group: - - - - - - - - - - -
/'_________
iSession Notes:
iType of Sessio£]_: ------------~=---==1
!:Group Note/Participation Form
1:
!Date Sep 2, 09 Client's Name: Manager (b)( 6 l
l;
!:i ~
!Proup Name: Cypress Group Leader(s): 6
(bJ( )
p
I$ess1on #
I'
11
J~r,cceptance Of Responsibility 3
:!Personal 01sclosures 3
\lt:mpathy for child and/or others 3
fl::novv'ledge & Understanding of
l
,ftffect1ve Anger ~vlanagernent Strategies
iA:hxious
i,r-i .. i
:·vDilfloen,
CJ ,~r<
I~ !-"\It,.. ::.I r,z, i-f• J I
I "-' ~~ l ,
iOiher
l /7./20! l
i'
I
!Additional
t
Comments or Closinq ~
Summar'y.
!Client was able to ident:fy 3 physical cues occurring in his body when he get angry.
~-~~-~t vvas engaged and active in group discussion this week.
!Plan Status (
~Diagnostic Impression r· ·
if------- ·-------------------------
!]Recommended Referrals:
w----;~-------------·---·-- . .. -----------------------------------
I
[;ln~Hous~ FF:_c: jExternal M1htary: !External Civilian: jTri-·Care: ;
l 7/20 I I
1 d,St.; I J (JJ ,JJ
'
l
'
!SeSSIOn # 10
~
jContent of Group Masculinity Traps
h
F
~~i.\cceptance Of Responsibility 3
1;Personai Disclosures 3
!Empathy for child and/or others 3
Kno•NiecJge & Understanding of
,Effective A.nger Management Strategies
G
;V1otivation for Change 3
I:Insight & Self Awareness into
!Behavior
/3
: Respectful attitude 4
I1pverali Participation 4
i,h.FFECT THERAPEUTIC CONCERNS
/bpbeat xxx Incident of Re-abuse
l
~puarded x Suicidality
,!Resentful Increased Risk of Re-abuse
~(~a!rn r1ostile, Aggressive Behavior
:Fr·ustrated Increased Depression
I'
dReflective Increased Stress
I,
/ ijlappropriate Other ________________ _
1Fflat None x
!j
Jl~ngry
fc;_ ,
:)aa
I i .
ftj\nXIOUS
!Confident x
i'
111egretful
!Other
'
l 7 201 1
i,c\ddittona! Cornments or Closing Summary:
jCI1ent reported that he is not serious about anyone He agreed 1,vith the group that he does
~
):~?_t_sh_~~~-1-_li_n~_eif_?penly with a partner because he sees it as a weakness and unnecessary I
t~!_an ~!_<l~-~~--------·--
__ -------------------------·-----------
~pia_,gnostic lrnpression r (·
-------------====--~-~
.J
f;Recommended Referrals:
._-----··-----------·-··--------·------------------------·-----·-·---------------------------~
I
i'ln-House FFSC: \External Military: !External Civilian: jTri-·Care:
f.
H
H-"------ ~------------···~·----·--·----
i Signature of Provider:
I' --~~-·--·-·-··~---"·-----------
(b)f6)
1 7 201 i
! ~ f ll 1! . \!I : { }J l I l J
!Clinical
'
Contact Note
!Case Number 60118 Client Name: (b)(6)
(b)(6)
!Group Nanx:;: Cypress Group Leader(s)
l
Session# 9
;\cceptance Of Responsibility 3+
I Personal Disclosures 4
l Ernpathy for child andior others 3
Respectful attitude 4
Overall Participation 4
!
!AFFECT THERAPEUTIC CONCERNS
!Upbeat xxx x Incident of Re-abuse
!Guarded Su1crdality
!Resentful x Increased Risk of Re-abuse
!Caim Hostile, Aggressive Behavior
!Frustrated Increased Depression
!Reflecti 1Je x Increased Stress
!inappropriate Other _ __
iFiat None x
1Angry
Sad
'•Anxious
!Confident
,,Regretful x
(;Oth·::r
!/~()! l
Ll\cJclit:onal Comments or Clos1ng Summary.
!Client shared his incident that brought him into group. Client reported he is no longer vvitrl tllat
[partner, but he regrets the choices he made that day. He admitted he was irritated with the
,r~elf=]r~~~C wj]_o c~_t;;_~e police and 'embeltished:_~~e re2_ort _________________________ _
:Plan Status c
ilQ-:!agn~stic lmpressio_n r· --·--------------------------
J:!3.~.£~Jmm~!'ded Refe_rr_a_l~s_:- - - - - - - - - - - - - - , - - - - - - - -
iJn-House FFSC: !External Military: !External Civilian: !Tri-Care:
11--, '"'
~~~~~~~--~-----~~~fSi~na~~~~cios _____ j
hll /i;2() II
;clinical Contact Note
:case Number 60118 Client Name: (b)(6}
i\Time Spent 0
''·--·---------------------------
!iNumber of !ndlvid_uals Seen: 0 ----- ___
1
f[!:y pe of Cou nse!in g _G_r_o_u-"p_:___________________j T¥. pe of Sess i o t_:l~-------------------1
j1Session Notes:
j:Group Note/Participation Form
L
I'
iOate: 24 June 09 Client's Name: (b}(G) Case Manager (b)(G)
iJ
!$ession # 8
li
~~ontent of Group
!Discussion on recognizing & setting boundaries with others using "I statements' as we!!
!as
11
recognizing 8< accepting their partner's differences
lh
'-
=none, 2=rarely; J=somet1mes: 4=often: 5-=very often)
ll
1
.f\cceptance Of Responsibility 3
Personal Disclosures 3
Empathy for child and/or others 2
:knowledge & Understanding of
!Effective Anger Management Strategies
:~
i\;1otivation for Change 3
1'nsigl1t & Self Awareness into
E3ehavior
,)
,)
*espectfu! attitude 4
cj)verall Participation 4
1
I
A,FFECT THERAPEUTIC CONCERNS
l~pbeat xxx Incident of Re-abuse
C~uarded Suicidality
~esentfullncreased Risk of Re-abuse
Calm x Hostile. Aggressive Behavior
~rustrated Increased Depression
F~ef!ective Increased Stress
l!i1appropriate Other______~--------
F;Iat None x
i~ngry
clad
'-~;
i\nxious
,.; '"d en t
uOilll. X
i
IV\dditional Comments or Closing Summary:
lCI1ent was a little on the quiet side today He was attent1ve and gave feedback when asked
JFI_i~nt's -~dea is to give back wilateve~ you get as_~w~_; to teach_ the C?_~2_~r_§ le~~on~-----------------l
!Plan S!atus r------------------~----------.
\fJi~gn_?_S.tic Impression ( ·
··,
___ ,_----------------------------------------~
-------------------------1
I~Wo~-"£!;~ Referra ~x tern a! 'i Mi1ita;y-:-- -----rE-xte·r~-;IC;~~ ---lfri-ca r;-3-
1,1----
··' ------- ---------r-:·------------
1\~~gn~~~~=- of Provi_der_ _______ 1 Da~e of -~lg~~~-~:: 7/31 /20_~9 _________ j
6
(bl( )
'' ' .
h [ hlil J ·,_.._: ll !•..' .lla\ \ - mi lcomronclll.'./ ronll s.' Prtll t.\ [l Forill').<lSj!\ !!/20 l I
I t.Lt:\.. I \!1 --' -·'
lbate
;!
17 June 09 Client's Name· (b)(6)
Case manager: (b)(6)
li
i<
~~jf"Oup Narne ___ Cypress ___________ C3roup l_eader(s). (b)(6)
\l
IPession # 7
I!
l~ontent of Group: Revenge
Jl
ll
I'(1'l 2=none. 2=rarely:
3 4 5 1\J/A
3=sometimes: 4=often. 5=very often)
1(-\cceptance Of Responsibility 4
I,personal Disclosures 4
i!~mpathy for child and/or others 3
IJ'<:nov:ledge & Understandina of
/1Erfect1ve Parenting Strateg1~s 3
lrv1otivat1on for Change 4
/IJlSight & Self Awareness into
1f'3ehavior 4
r1~espectful attitude 4
1
:(j)veralf PartiCipation 4
ll
/,L~FFECT THERPPEUTIC CONCERNS
Ii)pbeat Incident of Re-abuse
jc?uarded Suicidality
iHesentful Increased Risk of Re-abuse
'qa!m x Hostile, Aggressive Behavior
l
1
ryustrated Increased Depression
/f·fef!ect1ve x Increased Stress
i ll)appropr~ate Other____
tFiat None
iril!r-gn·
1 1 1 .. j t
I~:~ad
I,.! .
/P,nXIOUS
I'I("' f"ri--
· ,-;Oil>lut:.!ltl
-,+
IR:egretfur
rif~'·e·'
-...-·,l l I
itional Comments or Closmg Summary
_ (b)(G) continues to do vvell in group and IS engaged m the process He enthusiastically made
l!up two absences in 1ndtvidual sessions, picking the topics and working through the issues. He
\'pn=.:sents as genuinely interested in building equity in his relationship.
!'
I~
IEI<l~l-~!<l!US~-----'---~~--_·_:_i ~-__:=__~_:_·___________:___
.
' _,_.------------------------~
---------,
!biagnostic Impression ' t:: ' -
!R~-co;~~me-~ded-R-efer;;i~~--
· -
-------------------------------------
I
/1~~-H~~-~e- FFSC: - IExtern-~ita;:V_:_ \ExternaTClvii-i~-----ITri-c~~-:------
!·;-._---- f\ E
b·!
.j(\
'2() 1l
l
!Clinical Contact Note
i
(b)(6)
lCase Number 60118 Client Name:
!contact Date: 6/12/2009
j'------·-----,
L 7 '](iiI