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FAP Clinical Contact Note
Case Number 20434 Client Name:

(b)(6)
-~--

-~·--

Contact Date: 8/9/2006

Clinical Provider:

Time Spent: 0.75

Type of Contact: Phone

(b)(6)

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.

On 8/9/06, TC from

SIGNATURES
Signature of Provider:

(b)(6)
--

~-

The case was discussed.

-~

--·-----···-

(b)(6)

Date of Signature: 81912006

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FAP Clinical Contact Note
Case Number 20434 Client Name:

1 L 01 1'-l-

(b)(6)

Contact Date: 8/2/2006

Clinical Provider:

Time Spent: 0.75

Type of Contact: Phone

(b)(6)

Collateral Contact:
Summary of Contact:
(b)(6)
On 812/06. TC from
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

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I=AP Clinical Contact Note
Case Number 24831 Client Name:

(b)( 6 )

Contact Date: 4/9/2008

Clinical Provider:

Time Spent: 0

Type of Contact: Other

(b)(6)

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
Signature of Provider

(b)(6)

Date of Signature: 4/9/2008

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lAP Clinical Contact Note

~ase Number 25874 Client Name:

(b)(6)
---··

Clinical Provider:

! :::ontact Date: 5!7/2008

------·--

(b)(6)

Type of Contact:

ime Spent: 0.25

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
the med;cal mpmt. pohce ceport and the pcepondecance of choical intocmation as well as the
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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ADM

UHf:~,

(b)(6)

~ignature of Provider:
--·

Date of Signature: 5!712008

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fAP Clinical Contact Note
(b)(6)

~ase Number 25874 Client Name:
F:;ontact Date: 1!2812008

Clinical Provider:

[rime Spent: 0.5

Type of Contact: Phone

(b)(6)

---

-- --

~

~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.

S!{3NJ\ TttnE~)
·~·~~

~ignature of Provider:

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(b)(6)

---

Date of Signature: 1/28/2008

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~AP Clinical Contact Note
Case Number 25874 Client Name:

(b)(6)

' ontact Date: 9/1 0/2007

Clinical Provider:

r lme Spent: 0.25

Type of Contact: Phone

(b)(6)

-··-------

( ollateral Contact:

ummary of Contact:

pn 9/10/07, TC to the ADM at

(b)(6)

ADM reported that he has completed 26/52 group sessions. He reported !hilt he
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)

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Date of Signature: 9/10/2007

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fAP Clinical Contact Note
(b)(6)

, ~ase Number 25874 Client Name:

---·~-·

(b)(6)

Contact Date: 1/5/2007

Clinical Provider:

iTime Spent: 0.5

Type of Contact: In Person

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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Signature of Provider:

(b)(6)

j Date of Signature:

1/512007

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rAP Clinical Contact Note
~ ase Number 25874 Client Name:

(b)(6)

-(b)(6)

Clinical Provider:

Pontact Date: 12/13/2006
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
return call.
S!(;fN/\

(b)(6)

(cell phone). CM left a vo1ce message regardlllg the outcome of CRC and requested

iJfiL:::~·

(b)(6)

Signature of Provider:

Date of Signature: 12/13/2006

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F'AP Clinical Contact Note
(b)(6)

)ase Number 27076 Client Name:

----------

Contact Date: 3/27/2007

Clinical Provider:

~ime Spent: 0 5

Type of Contact: Phone

(b)(6)

------------------1

: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
oblems but have worked through 1!.

1r

1~ M prov•ded h1s email address as

lr 1s Cell #:

(b)(6)

: ignature of Provider:

and home#

(b)(6)

(b)(6)
(b)(6)

and ADF's:

(b)(6)

I

Date of Signature: 3!2712007
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ J

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IFAP Clinical Contact Note
(b)(6)

~ase Number 27076 Client Name:

---.----·

(b)(6)

Contact Date: 11/17/2006

Clinical Provider

Time Spent: 3.5

Type of Contact: In Person

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.
:..,)ft; f~/\ TUfiCS

~ignature of Provider:

f\P'PLi'Jf)f\C>:f. f\fCJ! L
umber Appendage Note

Eate

(b)(6)

of

Sign~~ure: 11/20/2006

-

SM also states that he has an appmt with Ship's Psychologist for a
depression/medication evaluation.

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Nan~e Date
11/20/2006 4:18:00
PM

12/1412010

FAP Clinical Contact Note
(b)(6)

Case Number 27076 Client Name:

~

Contact Date: 1/15/2008

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

Collateral Contact:

(b)(6)

--

~

Summary of Contact:
(b)(6)
TIC to CFAR,
(b)( 6 )
has not been attendrng group in the
of the Nimitz. Informed CFAR that SM .
•ommunrty and has not bePn in contact with CM as he was asked to after the recent court heanng. CFAR will forward
(b)( 6)
who is SM's CM. CMC's # is
(b)( 6 )
nforrnalion to

--

--~

ltiHf S
Signature of Provider:

(b)(6)

Date of Signature: 1/15/2008
---

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12/14/2010

I
IFAP Clinical Contact Note
Case Number 27076 Client Name:

(b)(6)
(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:

Signature of Provider:

ht1lp:

(b)(6)

__

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12/14!20 I 0

: FAP Clinical Contact Note
Case Number 27076 Client Name:

(b)(6)
(b)(6)

Contact Date: 12/28/2007

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

-------------

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.
Ul\!

Signature of Provider:

' !\

(b)(6)

~--------...~.l_o_a_te_of Signature: 12128;<'007

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]Date

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(b )(6)

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FAP Clinical Contact Note

1

Case Number 36618 Client Name:

(b)( 6)

(b)(6)

Contact Date: 7/24/2007

Clinical Provider:

Time Spent: 1.5

Type of Contact: In Person

Collateral Contact:
Summary of Contact:
· Group Note/Participation Form

Pate: July 24, 2007 Client's Name:
(b)(G)
C:Asl? Manager!b)(G)
~roup Name: SAPPHIRE Group Leaaer(s):
(b)(6)
Session# 2
f..-Ontent of Session: Communication Skills. Assertive vs. aggressive, asking for behavior change respectfully, ''I" statements.
P,ssign a number value to each category: 1=none; 2=rarely; 3::sometimes; 4:::often; or N/A
f\cceptance of Responsibility: 3
Personal Disclosures: 3
mpathy for others: 3
nowledge & Understanding of Effective Parenting Strategies: nia
~otivation for Change: 2
~espectful attitude: 4
Dverall Participation: 3
ut an "X" for those that apply:
FFECT: THERAPEUTIC CONCERNS:
pbeat Incident of Re-abuse
uarded Suicidality
esen!ful Increased Risk of Re-abuse
aim Hostile, Aggressive Behavior
rustrated Increased Depression
IF eflective X Increased Stress
I appropriate Other:
if at None
llngry

l~!ad

llrXIOUS

lc lonfident
IF~gretful
lc her (state type)
lr.h~AMI="'TS or SUMMARY:
(b)( 6 ) participated appropriately, and shared her role play with the group. Her role-play partner complimented her for
d ing an excellent JOb of asking for change respectfully.

;;!GNATURES
S~gnature

of Provider:

(b)(6)

Date of Signature: 9/12/2007

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jFAP Clinical Contact Note
·Case Number 36618 Client Name:

(b)(6)
(b)(6)

Contact Date: 7/17/2007

Clinical Provider:

Time Spent: 1.5

Type of Contact: In Person

Collateral Contact:
Summary of Contact:
Group Note/Participation Form

Date: July 17, 2007 Client's Name:
(b)(6)
:::ase Manager(b)(6)
(b)(6)
Group Name: SAPPHIRE Group Leaaer(S):
Session# 1
Content of Session: Communication Skills, Process. With numerous new members, much of the group time went toreestablishing Group Guidelines, and building rapport and cohesion in the group through processing Check-In events.
Assign a number value to each category: 1=none; 2=rarely; 3=sometimes; 4=often; or N/A
Acceptance of Responsibility: unk
Personal Disclosures: 2
Empathy for others: unk
Knowledge & Understanding of Effective Parenting Strategies: nia
Motivation for Change: unk
Respectful attitude: 3
Overall Participation: 2
Put an "X" for those that apply:
AFFECT THERAPEUTIC CONCERNS:
Upbeat Incident of Re-abuse
Guarded X Suicidality
Resentful Increased Risk of Re-abuse
Calm Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
Inappropriate Other:
ll=lat None
V\ngry

!sad
lt\nXIOUS

~onfident
fiegretful
Pther (state type)

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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i=AP Clinical Contact Note
Case Number 36618 Client Name:

(b}(6}

Contact Date: 12/17/2007

Clinical Provider:

(b}(6}

Type of Contact: In Person

ime Spent: 1.5

~ollateral Contact:
Summary of Contact:
!Group Note/Participation Form
date: December 4, 2007 Client's Name:
roup Name: SAPPHIRE Group Leadeqsr
ession: #16 (for this client)
bsent:
ontent of Session: Negative Self-Talk

~

(b}(6}

Case Manager:(b}(6}

(b}(6)

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
vera II Participation: 4

lc

t an "X" for those that apply:
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)

i

C MMENTS or SUMMARY:
(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.

Tt s was

~IGNATURES

S

~nature

of Provider:

(b}(6)

Date of Signature: 12/17/2007

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AP Clinical Contact Note

ase Number 36618 Client Name:

Contact Date: 11/13/2007

(b)(6)
Clinical Provider:

ime Spent: 1.5

(b)(6)

Type of Contact: In Person

bollateral Contact:
~urn mary of Contact:
Group Note/Participation Form
!

ate: Nov. 13, 2007 Client's Name
(b)(6)
Case Manager: (b )(6)
roup Name: SAPPHIRE Group Leader(s):
(b)(6)
ession: #14 (for this client)
bsent:
ontent of Session: Progression of Violence.

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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
fl.ective X Increased Stress
I ppropnate Other:
F t None X
A gry

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C nfident
R gretful
0 er (state type)

or SUMMARY:
asked for support today as she reflected on whether she did everything she could have to help her marriage work.
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.

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6
(b)( )

IGNATURES

S ~nature of Provider:

(b)(6)

Date of Signature: 11115/2007

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tAP Clinical Contact Note
(b)( 6)

c ase Number 36618 Client Name:

(b)(6)

ontact Date: 8/7/2007

Clinical Provider:

Ime Spent: 1.5

Type of Contact: In Person

~ollateral Contact:

ummary of Contact:
Group Note/Partictpation Form

It ate: August 7, 2007 Client's Name
IC roup Name: SAPPHIRE Group Leader(s):

Case Manager: (b)(G)

(b)(G)

(b)(6)

I~ ession # 4

IC ontent of Session: Understanding Anger, and dealing with it respectfully.
IJl sslgn a number value to each category: 1=none; 2=rarely; 3=sometimes; 4=often: or N/A
1.<~ r;ceptance of Responsibility: 3

IF ~rsonal Disclosures: 3

t;;rnpathy for others: 3
Krowledge & Understanding of Effective Parenting Strategies: 3
N otivation for Change: 3
~specttul attitude: 4
cterall Participation: 4
P~t an "X" for those that apply:
A FECT: THERAPEUTIC CONCERNS:
U Jbeat Incident of Re-abuse
G Jarded Suicidality
R 3sentful Increased Risk of Re-abuse
C 11Im Hostile, Aggressive Behavior
F ~strated X Increased Depression
R flective X Increased Stress
In ppropriate Other:
Fl3t None X
A gry
s d
A XIOUS
C nftdent
R1t9retful
01fler (state type)

~~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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Clinical Contact Note

¢ase Number 36618 Client Name:

6
(b)( )
·----~------

f-ontact Date: 8/2/2007

Clinical Provider:

ime Spent: 1.5

(b)(6)

Type of Contact: In Person

"ollateral Contact:
:;ummary of Contact:
~roup Note/Participation Form

9ate: July 31, 2007 Client's Name:

(b)(6)

roup Name: SAPPHIRE Group Leader(s):

Case Manager: (b)(6)
(b)(6)

jE!;lssion # 3
ICI::mtent of Sesston: Effects of DV on Children

~

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

E~pathy for others: 3
l
Kfowledge & .Understanding of Effecttve Parenting Strategies: 3
M tivation for Change: 2
R spectful attitude: 4
Oterall Participation: 4

P~t

an "X" tor those that apply:

A~FECT: THERAPEUTIC CONCERNS:
U~beat lnctdent of Re-abuse

G~arded Suicidality
REf'entful Increased Risk of Re-abuse

C~m Hostile, Aggressive Behavior
Fn strated Increased Depression
Re lective X Increased Stress
In<: ppropriate Other:

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Fl.. None X

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her (state type)

O:OMMENTS or SUMMARY:
(b)(6)
was very interactive in this sess1on. She gave several examples relating to specific effects of the domestic violence
her son

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SIGNATURES
~ignature

of Provider:

(b)(6)

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Date of Signature: 81212007

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IFAP Clinical Contact Note

I Case Number 37009 Client Name:

Clinical Provider:

\ Contact Oat"' 1011 812007

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(b)(6)

Time Spent: 1

(b)(6)

Type of Contact: Phone

Collateral Contact:
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:

lttj)S

(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
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

!Type of Contact: In Person

IType of Session: Group

Session Notes:
Group Note/Participation Form
(b)(6)
Case Manager: (b)( 6)
Date: 08/29/07 Client's Name:
Group Name: Cypress II Group Leader(s): TW & LH Sessron #(for this client): 9
Assign a# value to each category: 1=none; 2=rarely; 3=sometimes; 4=often; or N/A
Acceptance of Responsibility: 1
Personal Disclosures: 2
Empathy for others: 3
Knowledge & Understanding of
Effective Anger Management Strategies: 2
Motivation for Change: 1
Respectful attitude: ·3
pverall Participation: 3
Put an "X» for those that apply:

~FFECT:
pbeat
uarded

rntluiX

aim
rustrated Reflective
napproprrate
Iat

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
COMMENTS 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)

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IP an Status

,·.u

ID agnostic Impression
R~commended

Referrals:

lr House FFSC:
F p

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External Military:

< IGNATURES

S gnature of Provider:

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(b)(6)

External Civilian:

ITri-Care:

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Date of Signature: 8/31/2007

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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
Number of Individuals Seen: 0

jType of Contact: In Person
jType of Session: Group

Type of Counselin~ Group: Offender Group
Session Notes:
Group Note/Participalton Form

(b )(6) Case Manager:(b)( 6)
Date: 08/15/07 Client's Name:
Group Name: Cypress II Group Leader(s): TW & LH Session# (for th1s client): 8
Assign a# value to each category: 1=none; 2=rarely; 3=sometimes; 4=often; or N/A
Acceptance of Responsibility: 1
Personal Disclosures: 2
Empathy for others: 2
Knowledge & Understanding of
Effective Anger Management Strategies: 1
Motivation for Change: 1
Respectful attitude: 3
pverall Participation: 3
Put an "X" for those that apply:
A.FFECT:
~pbeat

puarded
~esentful

X

~aim

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

..

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,,:,•;,;

;

D agnostic Impression
A ~commended Referrals:
111 House FFSC:
F p
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External Military:

IGNATURES

S gnature of Provider:

;".i;

(b)(6)

ITri..Care:

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Date of Signature: 8/31/2007

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Clinical Contact Note
(b)(6)

Case Number 37009 Client Name:
Contact Date: 8/8/2007

jType of Contact: In Person

Time Spent: 2
Number of Individuals Seen: 0
1 Type of Counseling Group: Offender Group

I

jType of Session: Group

Session Notes:
Group Note/Participation Form

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)

~an Status

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ID agnostic Impression

• .. i

iA ~ommended Referrals:

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F p

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External Military:

External Civilian:

ITri-Care:

, !GNATURES
(b)(6)

S gnature of Provider:

IDate of Signature: 8/31/2007

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Clinical Contact Note
Case Number 37009 Client Name:

(b)(6)

Contact Date: 712512007
Time Spent: 2

!Type of Contact: In Person

1 Number of Individuals Seen: 0

j Type of Counseling Group: Offender Group

I Session Notes:
Note/Participation Form
IGroup
Date: 7125107 Client's Name

(b)(6)

!Type of Session: Group

Case Manager:

(b)(6)
(b)(6)

Group Name: Khulani I Group Leaoer(s:
Sessions Attended: 5 Absent: Halfway pomt: Final Session:
Content of Group:
A new facilitator began with the group today" Introductions were conducted with all group members sharing his/her
presenting problem and the need for Family Advocacy services" A piece from SOS Basic Parenting skills was viewed by the
group and served as the basis for discussion for the class. Focus of group was to discuss positive parenting strategies and
effective discipline. This led to a discussion of different discipline techniques.
Ass1gn a number value to each category: 1=none; 2=rarely; 3=sometimes; 4=often; or N/A Acceptance of Responsibility: 3+
Personal Disclosures: 3
Empathy for others: 3
Knowledge & Understanding of
Effective Parenting Strategies: 3
Motivation for Change: 3+
Respectfulattitude:4
Overall Participation: 3
Put an "X" for those that apply:
AFFECT:

~pbeat

tluarded
Resentful
Calm X
rustrated
~effective X
pappropriate
Iat
ngry
ad
epressed
nxious
lc onfident
IF egretful
herapeutic Concerns:
I cident of Re-abuse
! Euicidality
I creased Risk of Re-abuse
I1-(oshle, Aggressive Behavior
reased Depression
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.

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-·---·-·

(b)(6)

.

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l'lotewartiCipatiOn Form
(b)(6)
Case Manager:
(b)( 6)
D te" 7/25/07 Client's Name:
(b)(6)
G oup Name: Khulani I Group Leader(s): 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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Empathy for others:
Knowledge & Understanding of
Effective Parenting Strategies:
Motivation for Change:
Respectful attitude:
Overall Participation:
1Put an "X" for those that apply:
AFFECT:
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.

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Plan Status

!.!(',

Diagnostic Impression
~ecommended Referrals:
~-House

FFSC:

AP

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SIGNATURES
~ignature of Provider:

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(b)(6)

External Civilian:

ITri-Care:

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Date of Signature: 816/2007

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Clinical Contact Note
(b)(6)

Case Number 37009 Client Name:
Contact Date: 7/18/2007

jT):pe of Contact: In Person

Time Spent: 3
Number of Individuals Seen: 0

jType of Session: Group

\ Type of Counseling Group: Offender Group
Session Notes:
1 Group Note/Particrpatron Form

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(b)(6)

Date' 7118107 Ghent's Name'

Case Manager: (b)(6)

Group Name; Cypress Group Leader(s):

(b)(6)

Session# 5
(1 :::none; 2=rarely;3==sometrmes;4=often;5:::very often)
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
f\FFECT THERAPEUTIC CONCERNS
Jpbeat Incident of Re-abuse
3uarded Surcidality
~esentful Increased Risk of Re-abuse
~-'aim X Hostile, Aggressrve Behavior
rustrated Increased Depression
eflective Increased Stress
Jnappropriate Other__________
lat None
ngry
ad
nxious
onfident
egretful
C ther

~ditional Comments or Closino SummMv" SM quiet and attentive.
(b)(6)

IP an Status

',,

lo agnostic Impression
IR ~commended Referrals:
lr House FFSC:
F p

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ITri-Care:

JGNATURES
S gnature of Provider:

(b)(6)

j Date of Signature: 712312007

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~AP Clinical Contact Note

'Case Number 38583 Client Name:

(b)(6)

Contact Date: 1011012007

Clinical Provider:

jTime Spent: 0.5

Type of Contact: Phone

(b)(6)

Collateral Contact:
(b)( 6)
Summary of Contact:
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
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.

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SIGNATURES

Signature of Provider:

(b)(6)

Date of Signature: 10/11/2007

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fAP Clinical Contact Note

. ~ase Number 38583 Client Name: C

(b)(6)

~ontact Date: 8/15/2007

Clinical Provider:

~ime

Type of Contact: Phone

Spent: 0.25

(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
Signature of Provider

(b)(6)

Date of Signature: 8/15/2007

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fAP Clinical Contact Note
Case Number 38583 Client Name:

(b)(6)

pontact Date: 7/11/2007

Clinical Provider:

~ime Spent 0.25

Type of Contact: Other

(b)(6)
~-------------l

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bollateral Contact:

!)ummary of Contact:
• On 7i11/07, case was presented at the CRC and substantiated. SM was identified as the primary offender of spouse abuse
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.

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SIGNATURES

H------------lgnature of Provider

(b)(6)

Date of Signature: 7/16/2007

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¢ase Number 38583 Client Name:

(b)(6)

Clinical Provider:

i "ontact Date: 7!212007

(b)(6)

Type of Contact: In Person

ime Spent: 05
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
ignature of Provider:

1!

(b)(6)

Date of Signature: 7!212007

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Clinical Contact Note
¢ase Number 38583 Client Name:
L
:pontact Date: 7/2/2007

ime

1

Sp~nt:

(b)(6)
·-

Clinical Provider:

0.25

(b)(6)

Type of Contact: Phone

;~ollateral Contact:
!~mmary of Contact
(b)(6)
CM discussed the upcoming CRC. SM confirmed that he has been attending his 52
I n 7!2107, TC to the SM a
#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
~

ignature of Provider:

(b)(6)

Date of Signature: 71212007

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FAP Clinical Contact Note
Case Number 42311 Client Name:

(b)(6)

Contact Date: 4/15/2008

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

(b)(6)

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

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Administrative Note
Case Number 42311 Client Name:
Contact Date: 10/17/2007
Provider's Name:
(b)(6)

(b)( 6)

Appointment Administration:

(b)(6)

Administrative Notes:
SM will be attending Court Ordered 52 week civilian treatment program - court did not
authorize Navy FAP program.

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't=AP Clinical Contact Note
' [;ase Number 45997 Client Name:

(b)(6)
~-----·-

Contact Date: 6/4/2008

Clinical Provider:

ifime Spent: 0

Type of Contact: Other

(b)(6)

Collateral Contact
~ummary of Contact:
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.

1Case

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(b)(6)

Date of Signature: 619!2008

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'FAP Clinical Contact Note
. Case Number 45997 Client Name:

(b)(6)
(b)(6)

Contact Date: 5/27/2008

Clinical Provider:

Time Spent: 0

Type of Contact: In Person

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.

~ignature of Provider:

(b)(6)

Date of Signature: 5/27/2008

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' FAP Clinical Contact Note
, Case Number 45997 Client Name:

(b)(6)

;

Contact Date: 4/24/2008

Clinical Provider:

Time Spent: 0.25

Type of Contact: Email

(b)(6)

Collateral Contact:
Summarv of Contact:
(b)(6)
just spoke with his Department Senior Chief.
(b)(6)
nspection today and he can not come over touuy.

will provide you an update tomorrow. Unfortunately we are domg an

JiR
(b)(6)
realth Services Department
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:
ent: l.tUI..;;JUUJ, ntJIII L"T, LUVO
o:
(b)(6)
Ubj8Ct:
(b)(6)

(b)(6)
IU.I/

ArvJ

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.
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
'R.
(b)(6)

it

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lt:p6-8316

ignature of Provider:

(b)(6)

Date of Signature: 4/24/2008

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rAP Clinical Contact Note
ase Number 46649 Client Name:

(b)(6)
~

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__

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-

---~---·-

[j,Pontact Date: 7/1/2008

---·-··-

Clinical Provider:

ime Spent: 0.25

(b)(6)

Type of Contact: Email

: ;;oliateral Contact:
IIJiummary of Contact:
(b)(6)
1 1 !Had the follwing further commun1catton with

(b)(6)
Thank you; it's quite honorable for

today:
(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
9pon as he gets back I will touch base w1th him and set something up with you. Thanks again.

As

(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)
Clinical Provider:

ontact Date: 7/1/2008

i ime Spent: 0 25

(b)(6)

Type of Contact: Ematl

ollateral Contact:

1

~ 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)
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.
(b)(6)

--Original Message----om
(b)(6)
ent· Mondflv .hmA :iO ~OOR 1R·14
·h
(b)(6)
$ubject. RE Relaying "FOUO" Matenal

:i

(b)(6)
(b)(6) , as of nght now
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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~·---~------

$ignature of Provider:

(b)(6)

Date of Signature: 7/1/2008

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12/20/2010

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f AP Clinical Contact Note
(b)(6)

ase Number 46649 Client Name:
ontact Date: 6/25/2008

Clinical Provider:

ime Spent: 0.25

Type of Contact: Phone

(b)(6)

, ' oHateral Contact:
ummary of Contact:
he follow1ng email was sent today to

(b)(6)

(b)(6)
(b)(6)
I understand he has been attendmg
I would like to receive an update re:
t r 52 week court maodated DV omomm aod would hke to koow the oumber ot '"'"ODS he completed thos far lo addiUOD,
\I 1at was the outcome of
(b)(6)
evaluation at SARP? Thank you for your assistance.
vr

(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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f ignature of Provider:

(b)(6)

Date of Signature: 6/25/2008

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I
, FAP Clinical Contact Note
' Case Number 46649 Client Name:

(b)(6)

Contact Date: 12/14/2007

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

(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
(b)(6)

;ase Number 48961 Client Name:
~ontact

Date: 6/2/2008
fType of Contact: In Person

ime Spent: 1.5
~umber of Individuals Seen: 1

!Type of Session: Group

ype of Counseling Group: Offender Group
pession Notes:
proup Note/Partrcrpalion Form

~roup

Case Manager (b)( 6)

(b)(6)

Pate 5/28/08 Client's Name:

(b)(6)

Name Cypress Group Leader(s)

p8SSIOn # 1
1=none; 2=rarely;3=sometirnes;4=otten:5=very often)
~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
~FFECT THERAPEUTIC CONCERNS
Wpbeat Incident of Re-abuse
puarded Surcidality
Resentful Increased Rrsk of Re-abuse
palm Hostile, Aggressrve Behavior
rustrated Increased Depression
Reflective Increased Stress
nappropriate Other
lat None
~ngry
~ad

~nXIOUS
~onf1dent

Regretful
pther
Mdrtional Comments or Closinq Summary 1st session. SM is resistant
(b)(6)

Plan Status

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Diagnostic Impression
Recommended Referrals:
n-House FFSC:

'.;

-.,
:} ..

!External Military:

!External Civilian:

ITri-Care:

SlGNATUF1ES

Signature of Provider:

(b)(6)

IDate of Signature: 6/2/2008

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12/13/2010

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F'AP Clinical Contact Note
Case Number 48961 Client Name:

(b)(6)

Contact Date: 3i31 /2008

Clinical Provider:

Time Spent: 0.5

Type of Contact: Email

(b)(6)

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.

t

hank

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

II ps://ffsmi s.c n ic. navy .mi l!componcnts/forms/PrintAIIFornls.aspx

12/13/2010

~linical Contact Note
~ase Number 49927 Client Name:

(b)(6)

feontact Date: 3!2712008
rrime Spent: 1 5
Number of Individuals Seen: 5

jType of Contact: In Person

rrype of Counseling Group: Offender Group

jType of Session: Group

fSession Notes:
iSM participated in group discussion Reported to group 1t was his final sessron. Received encouragement from other group
~embers SM requested 1f he might return, as he received help and support from the group.
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:

Signature of Provider:

1

IExternal Military:
(b)(6)

jExternal Civilian:

jTri-Care:

IDate of Signature: 3/28/2008

t ps:/!fC..,mis.cn ic .navy. m i 1/components:f(~mns/PrintA II Forms.aspx

12/112() 1(

Clinical Contact Note
Case Number 49927 Client Name:

(b)(6)

Contact Date: 3/13/2008
jType of Contact: In Person

Time Spent: 1.25
Number of Individuals Seen: 6

jType of Session: Group

Type of Counseling Group: Offender Group

Session Notes:
Min1mal participation by SM When asked, SM did not use cell phone for texting during group
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:

Signature of Provider:

I External Military:
(b)(6)

I External Civilian:

I

Date of Signature: 3/14/2008

h tps:!/ffsm is.cnic. navy .111 i 1/com poncnts/f()rms/Pri nt/\!1 Forms.aspx

ITri-Care:

Clinical Contact Note
pase Number 49927 Client Name:

(b)(6)

Contact Date: 3/6/2008
rTime Spent: 1 5

jType of Contact: In Person

Number of~~~ividuals Seen: 5
rrype of Counseling Group: Offender Group
!Type of Session: Group
Session Notes:
Group viewed and dtscussed a Video of chtld abuse from the child's perspecttve Generational patterns dtscussed and
members sl1ared how conflict WaS handled Ill their homes and the effect on them.
pM reported a qwet week with no provocative or aggress1ve incidents.
No indication of clinical nsk mcludmg: child/spouse abuse, threatsfdanger to self/others. and substance abuse: No indtcatton
pf suictdal or homicidal tdeatton or thought or mood disorder
Plan Status
piagnostic Impression
~ecommended

Referrals:

IExternal Military:

n-House FFSC:

Signature of Provider:

(b)(6)

IExternal Civilian:

ITri-Care:

J

Date of Signature: 31712008

1 1ps://ffsm is.cnic.navy. mi I/com poncnts/f{wms/Pri ntAJ J Fnrms.aspx

11/}/2010

~linical Contact Note
~ase Number 49927 Client Name:
~o-ontact

6
(b)( )

Date: 2!29i2008

!Type of Contact: In Person
ime Spent: 15
~umber of Individuals Seen: 4
jType of Session: Group
ype of Counseling Group: Offender Group
~ession Notes:
~mimal partictpalion 1n group Necessary to remtnd SM to put cell phone away
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:

!External Military:

r-House FFSC:

~ignature of Provider:

1

(b)(6)

!External Civilian:

ITri-Care:

IDate of Signature: 2/29/2008

ps:!/ffsmis.cnic.navy .m i 1/components/forms/Pri nU\1 IF orms.a~px

12/3/2010

:linical Contact Note
t;ase Number 49927 Client Name:

(b)(6)

::ontact Date: 2/2112008
ime Spent: 1.5

jType of Contact: In Person

1.---~------------------------------------------------~

IJumber of Individuals Seen: 8
jType of Session: Group
ype of Counseling Group: Offender Group
~~~----------~--~----------~----------------------~
session Notes:
3roup dtscussed the presentatton of the self soothing and led through two dtfferent forms of self-relaxation Recap of use of
ime outs and self-soothmg.

,M reported a qutet week wtth no incidents.
>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:

Signature of Provider

1

IExternal Military:
(b)(6)

!External Civilian:

ITri-Care:

IDate of Signature: 2/25/2008

lps:l/ffsm is.cnic.navy .mil!componcnts!forms/PrintAII Forms.aspx

12/J/2() 10

Clinical Contact Note
Case Number 49927 Client Name:

(b)(6)

Contact Date: 2i1 /2008
I Type of Contact: In Person

Time Spent: 1.5
Number of Individuals Seen: 7

1_T~y_,_p_e_o_f_C_o_u_n_s_e_li_n,:,e:g_G_r_o_u-'-p_:_O_ff_e_n_de_r_G_ro_u.:...p_ _ _ _ _ _ _ _ _ _ ___.l Type of Session: Group
Session Notes:
SM completed weekly check-in denres problem srtuatron or aggressron rn last week.

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:

Signature of Provider:

I External Military:

(b)(6)

I External Civilian:

ITri-Care:

IDate of Signature: 211/2008

I tps:/illsmi :-;.cnic. navy .mi l!components/forms/Pri ntA IIForms.aspx

12/3i~O I (

Clinical Contact Note
Case Number 49927 Client Name:

6
(b)( )

Contact Date: 1/25/2008
ime Spent: 1.5
Number of Individuals Seen: 7

jType of Contact: In Person

ype of Counseling Group:
!Type of Session: Group
l:lession Notes:
SM completed weekly check-in reportmg that he had "calmly stood up for my rights and expressed my feelings responsibly"
penied any problem Situation or aggression
3roup reviewed control/violence wheel and discussed blocks to effective communication
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:

Signature of Provider:

!External Military:

(b)(6)

IExternal Civilian:

jTri-Care:

j Date of Signature: 1/25/2008

h tps:f /ffsmis.cnic .navy .mi !;components/ formsiPri ntAII hwms.aspx

J 213120

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FAP Clinical Contact Note
Case Number 49927 Client Name:

6
(b}( )

Contact Date: 1/13/2008

Clinical Provider:

Time Spent: 1

Type of Contact: Phone

(b)(6)

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

Signature of Provider

(b)(6}

Date of Signature: 1113/2008
~-------------'----------------------'

I tps:/;ffsm is.cnic.navy. mil/componcntslforms/PrintAllF orms.aspx

l :2iJ!20 I 0

Clinical Contact Note
Case Number 49927 Client Name:

6
(b)( )

Contact Date: 1!11/2008
jType of Contact: In Person
Time Spent: 1 .5
Number of Individuals Seen: 7
JType of Session: Group
Type of Counseling Group:
Session Notes:
SM completed weekly check-In form. Identified success as 'calmly stood up for my nghts and expressed by feelings
responsibly" SM reported the problem situation as "I hate the command that I work for, I smiled and nod" SM denies
aggression thiS week.
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:
!G lA

IExternal Military:

IExternal Civilian:

ITri-Care:

Jl~

Signature of Provider:

(b)(6)

j Date of Signature:

h tps://JTsm is.cnic.navy .mi Jicomponcnts/forms/Pri ntAII Forms.aspx

1/1112008

I 2/3/20 I 0

:li nical Contact Note
:::ase Number 49927 Client Name:

(b)(6)

:::ontact Date: 1/7/2008
ime Spent: 1 5

jType of Contact: In Person

"..umber of Individuals Seen: 6
ype of Counseling Group:

jType of Session: Group

3ession Notes:
3roup revrewed and discussed a video presentation of communicatron differences between males and females and effectrve
approaches to use Focus of expression of appreciation and attention
\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:

Si· . i/\

!External Military:

I t - - - - - - - - - - · · -......

$ignature of Provider:
~-

1

.

IExternal Civilian:

jTri-Care:

:ES
(b)(6)

IDate of Signature: 1/712008

tps://ffsm i s.cn ic.na" y .mi 1/componcntslforms/PrintAII f< orms.aspx

I 2/3/20 I 0

Clinical Contact Note
Case Number 49927 Client Name:

6
(b)( )

Contact Date: 1/3/2008
Time Spent: 1.5

!Type of Contact: In Person

Number of Individuals Seen: 6
Type of Counseling Group: Offender Group

jType of Session: Group

Session Notes:
The Group viewed and discussed a v1deo presentation of effecttve communication with significant others.
SM noted that he mtends to file for divorce.
No md1cation of additional reports mcluding: child/spouse abuse. threatsidanger to self/others. and substance abuse; No
homicidal or suicidal 1deatton or thought or mood disorder
Plan Status
Diagnostic Impression
Recommended Referrals:
In-House FFSC:

Signature of Provider:

IExternal Military:
(b)(6)

IExternal Civilian:

jTri-Care:

IDate of Signature: 1/1412008

lps://JJsm is.cnic .navy .rni 1/components/forms/Pri ntAIIFonns.aspx

12/3/20 I 0

Clinical Contact Note
Case Number 49927 Client Name:
Contact Date: 12/6/2007

(b)(6)

-------------------------------------------------------.

Time Spent: 0 5
Number of Individuals Seen: 4

jType of Contact: In Person

Type of Counseling Group: Offender Group

jType of Session: Group

Session Notes:
Group Note Session shortened due to power outage
Group discussed the nnage/role/mandates of being a male as exemplified 1n the movie "The Great Santin!" and their own
~ormat1on of their ideas of what it means to be a man, the messages they were g1ven, took in, lived out of
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:

1

(b)(G)

IDate of Signature: 12/13/2007

tps:!/f'fsmis.cnic .navy .mi Jicomponcnts/forms/PrintAilF orms.aspx

12/3/201 (

~linical Contact Note
~ase Number 49927 Client Name:
Contact Date: 2/15/2008

6
(b)( )

------------------------------------------------.

Time Spent: 1.5

jType of Contact: In Person

~--~------------------------------------------------~

Number of Individuals Seen: 5

Type of Counseling Group: Offender Group

jType of Session: Group

Session Notes:
SM reports on weekly check-In that he ''calmly stood up for my nghts" m an argument w/ his W. Demes aggress1on in last
f,veek
!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:

IExternal Military:

n-House FFSC:

Signature of Provider:

1

(b)(6)

IExternal Civilian:

jTri-Care:

IDate of Signature: 2i15/2008

ps:l/ffsmis.cnic. navy. m i1/componcnts/l(mnsiPri ntA II Forms.aspx

l2/Ji20 10

( linical Contact Note
( ase Number 50539 Client Name:

(8)(6)

ontact Date: 9/17/2008

11

!Type of Contact: In Person

me Spent: 1 5
umber of Individuals Seen: 1
llype of Counseling Group: Offender Group
I~ ession Notes:
C roup Note/Participation Form

!Type of Session: Group

I

(b)(6)

I[ ate: 9/17/08 Client's Name

I< roup Name: Cypress Group Leader(s):

Case Manager:(b)(6)

(b)(6)

li GSSIOn #
( =none: 2=rarely;3=sornetimes:4=often;5=very often)
. 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
FFECT THERAPEUTIC cm~CERNS
pbeat Incident of Re-abuse
uarded Suicidality
esentful Increased R1sk of Re-abuse
aim x Hostile, Aggressive Behavior
rustrated Increased Depression
eflective Increased Stress
l[lappropriate Other
lat None
ngry
ad
nxious
ont1dent
egretful
Dther
dditional Comments or Closinq Summary: SM participated in group discussion
(b)(6)

ian Status
Diagnostic Impression
i(ecommended Referrals:
n-House FFSC:

!External Military:

IExternal Civilian:

ITri-Care:

SIGNATURES
~ignature of Provider:

(b)(6)

j Date of Signature:

12/9/2008

--~-~--

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( linical Contact Note
(b)(6)

( ase Number 50539 Client Name:
!( on tact Date: 9/11/2008

ime Spent: 1.5
umber of Individuals Seen: 1

\Type of Contact: In Person

ype of Counseling Group: Offender Group

\Type of Session: Group

ession Notes:
sroup Note/Participation Form
(b)(6)

Date: 9/11/08 Client's Name:

3roup Name: Cypress Group Leader(s)

Case Manager (b)(6)

(b)(6)

~ession # 2
1=none; 2=rarely;3=sometlmes;4=often;5=very often)
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

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
Arlditioniil Comments or Closinq Summary: SM was quiet and attentive.
(b}(6)
(b)(6)
Case Manager
Navy Region Southwest
619-556-2090
Plan Status
Diagnostic Impression
Recommended Referrals:
In-House FFSC:

IExternal Military:

\External Civilian:

\Tri-Care:

SIGNATURES
Signature of Provider

(b)(6)

IDate of Signature: 9/11/2008

httns://ffsmis.cnic.navy.milicomponents/forms/PrintAllForms.aspx

12/22/2010

(

linical Contact Note

(

ase Number 50539 Client Name:

(b)(6)
---

I C on tact Date: 8/27/2008

IType of Contact: In Person

ime Spent: 1.5
I

r umber of Individuals Seen:

1

ype of Counseling Group: Offender Group

\Type of Session: Group

~ ession Notes:
IC roup Note/PartiCipation Form
1

(b)(6)

' [ate: 8/27/08 Client's NamE

,Croup Name: Cypress Group Leader(s):

Case Manager: (b)(6)

(b)(6)

I~ ession # 2

( =none; 2=rarely;3=sometimes;4=often;5=very often)
/- ceptance Of Responsibility 3

iF ~rsonal Disclosures 3
Ernpathy for child and/or others 3
1

.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

A FECT THERAPEUTIC CONCERNS

~ ~arded Suicidahty

pbeat Incident of Re-abuse

IR esentful Increased Risk of Re-abuse
C~lm x Hostile, Aggressive Behavior
F ustrated Increased Depression
f~~flective Increased Stress
lr;~ppropriate Other
Fat None
A gry
d
A XIOUS
C )llfident
R gretful
0 her

s

A ditional Comments or Closino Sllmmary: SM was quiet and attentive.
(b)(6)

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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clinical Contact Note

(b)(6)

Cj:!se Number 50539 Client Name
Cpntact Date: 4/2/2008
T ,-ne Spent: 1 .5
N~mber of Individuals Seen: 1
T pe of Counseling Group: Offender Group
S ssion Notes:
1<:: oup Note/Participation Form
D~te:

lc:

4/2/08 Client's

~Jame

(b)(6)

oup Name: Cypress Group Leader(s):

!Type of Contact: In Person
!Type of Session: Group

Case Manager

(b)(6)

(b)(6)

S ssion # 1

C :::none: 2=rarely;3=sometrmes;4:::often;5=very often)
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
rxious
pnfident

I~
I~ ther

~gretful

IP~ditronal Comments or Closing Summary: SM discussed the difficulties in committed relationship.
(b)(6)

IF an Status
I C!agnostic Impression

IF!ecommended Referrals:
h -House FFSC:

IExternal Civilian:

IExternal Military:

jTri-Care:

~IGr'IIATURES
~

ignature of Provider

(b)(6)

J

Date of Signature: 4/2/2008

p.PPENDAGE NOTE
~mber

I

!Appendage Note

!Provider's Name

!Date

I

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111

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!Date of contact should be 8/27/08

(b)(6)

112/9/2008 3:32:00 PM

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~AP

Clinical Contact Note

( ase Number 50539 Client Name:
~ontact Date:

2i1/2008

(b)(6)

Clinical Provider

ime Spent 0 25

(b)(6)

Type of Contact: Phone

:;ollateral Contact: GOVERNMENT AGENCY/ORGANIZATION
ummary of Cont?"t·
(b)(6)
(b)(6)
Received call from
;;tating that SM had been accompanied to court by
who stated the Judge
ad agreed SM could attend offender group at FAP instead ot 52 week DVRP. Referral made to superv1sor for enrollment of
M to FAP group. CM notified of referral and informed that SM was also enrolled 1n FACEd. class for 2/15.
SIGNATURES

Signature of Provider:

(b)(6)

Date of Signature: 2/1/2008

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12/22/2010

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Page 2 of 14

l'lHIJJ~

.t"\1:1

Clinical Contact Note
Number 24256 Client Name:

(b)(6)

\

~ontact Date: 4/25/2007

Clinical Provider:

time Spent: 0.25

Type of Contact: Email

(b)(6)

\

¢ollateral Contact: GOVERNMENT AGENCY/ORGANIZATION

··1---·--------------------------------------------l
$umm~rv nf

~I

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(b)(6)

i

Qidn't forget about you it's been a pam trying to reach someone at the treatment facility. He has been to 19 sessions plus 2
other rneetlrlgs (21 total). He has 2 sess1ons excused due to medical appts and one unexecused absence due to not having
nioney to pay for the session and he already owes them $55. 11ssued an MPO for 111m to stay away from his w1fe, for his
p\'otectlon as well and he is now res1ding 111 the BEO for the next 30 days.

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----(b)( 6 l
CIV Family Advocacy Center ,Family Advocacy Center
Fforn:
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

httj1s://ffsmis.cn ic .rwv y. mi llcomponcnts/fonm.!Prin!A liForms.aspx
l

12/27/2010

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· . nt AU 1-'orms

14

· · amlly Advocacy Representative
CPOA Fundraising Coordinator
!755 BRINSER ST., SUITE 1
AN DIEGO, CA 92136
WORK:6 i 9-556-2937
ell:
(b)(6)
MAIL:
(b)(6)
• ···Orioinal Messaoe·-··
rom:
(b)(6)
CIV Family Advocacy Center ,Family Advocacy Center
ant: Thursday, April i9i 2007 3:13PM

o:

(b)(61
(b)(6)

ub]ect

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
avy Family Advocacy Program
135 Dolphin Alley, Bldg. 261
an Diego, CA 92136·5185

i

hone; (619) 556·8827
AX: (619) 556·9473

mail:

(b)(6)

SIGNATURES
~ignature of Provider:

I

(b)(6)

IDate of Signature: 5/10/2007

hfps://ffsmis,cnic.navy.mil/components/formsfPrintAUForms.aspx

12/27/2010

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Clinical Contact Note
Number 24256 Client Name:

(b)(6)
Clinical Provider

(b)(6)

Type of Contact: Phone

for 90-day rev1ew. SM states he has completed 11/52 DVRP sessions in the communtly. He reports he
sess1ons. He 1s back living al home and 11e and CW are gettin9 along better.
(b)(6)

IS

learn1n9

Date of Signature: 1/29/2007

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12/27/20 I 0

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Clinical Contact Note
Case Number 37009 Client Name:

(b)(6)

Number of Individuals Seen: 0

_T:. .:y~p: .: e: . . o: . _f: . . .: _C. :.o: . _u.:. :n: . _s: . _el: . _in: .:gSL. : G.:. :r: . _o: . _u. cp. :. :. :.O:. :.f c: e.:. :n: . _d. :. er: . _G.:. : :. _ro:. . :u: .c_____________
p
jType of Session: Group

1 Session Notes:

Group Note/Participation Form
Date: 7i11/07 Client's Name:

(b)(6)

Case Manager(b)( 6)

~Group Name: Cypress Group Leader(s):

{b)( 6)

lsessron II 4

\(1 oonone; 2=rarely;3=somotrmes;4=often;5=very often)
I

~cceptance Of Responsibility 2
Personal Disclosures 2
!Empathy for child and/or others 2
knowledge & Understandrng of
J;:ttectrve Anger Management Strategies 2
{vlotrvation for Change 2
•Insight f!, Self Awareness rnto

I

!~ehavior

~espectful attrtude 3
pverall Participation 2

'
~FFECT THERAPEUTIC CONCERNS
Vpbeat Incident of Re-abuse
$uarded Suicidalily
~1osentful increased Fltsk of Re-abuse
Q.:alrn X Hos!Jio, Aggresstve Behavior
~rustrated Increased Depressron
~efleclive.lncreased Stress
lfiappropnato Other ......
~Ia! None
f-jng1y
~ad
/inxrous
qonfidont
Fjegretful
qther

~d1!ional
Comments or Closing Summarv: SM nuiAt AJld allentrve.
'
{b)(6)

External Civilian:

(b)(6)

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Page ll of20

Clinical Contact Note
(b)(6)

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

. mil/component ,;ronns/Print A llForms.aspx

J 2/27/20 I 0

Page !2 of20

Clinical Contact Note
(b)(6)

Case Number 37009 Client Name:
'Contact Date: 6/20/2007

6/20107 Client's Name:

(b)(6)

Case Manager: (b)(6)

,Group Name: Cypress Group Leader(s):

~eSS!On

(b)(6)

#2

k\ j ocnono. 2ooraroly ,3=SOrnHtlmes:4=0ften;5=Very often)
'

Acceptance Of Responsibility 2
Personal Disclosures 2
~mpathy lor child andior others 2
knowledge & Understanding of
!=ffeclivo Anger Management Strategies 2
~-11ot1vat1on for Change 2
lns1gt1t & Self Awareness into
{lehavior

;p

flespectful attitude 2
tpverall Participat1on 2
i
JIIFFECT THEF1APEUTIC CONCERNS
Wpbont Incident of Re-abuse
$uarded Su1cidality
fjlesentful lncroased Risk of Flo-abuse
O~alm X Host1Io. Aggressive Bel1aV1or

ilrustrated Increased Depression
Reflective Increased Stress
ithappropriate Other
---··-F\Jat Nona
;~ngry

Siad

~xious

CJonlident

F~grellul

Other
Atld1tional Cornments or Closinn S11mm"'"' SM was quiet and rellectivo.
.
(b)(6)

Military:

(b)(6)

External Civilian:

of Signature: 6/25i2007

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Contact Note
(b)(6)

Session Notes:
Group Note/Participation Form
(b)(6)
Date: 6/20/0I Client's ~Jame:
(b)( 6 )
Case Manager
(b)(6)
Group Name: Khulan1 I Group Leader(s):
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)

Military:

External Civilian:

(b)(6)

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6/25/2007

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Contact Note
(b)(6)

6/13107 Client's Name:
(b)( 6 )
Case Manager:(b)( 6 )
f~ame: Cypress II Group Leader(s). TW & LH Sess1on # (for this client): 1
a# value to each category 1=onone; 2~rarely; 3=sometimes; 4::=oflen; or NiA
f.l.ccet)tallCe of Responsibility: 1
D1sclosuros 3
for others: 2
nmvlec:Joe & Understand1r1g of
Management Strategies.
for Change 1
attitude: 3
Participation: 3
an ·x for those that apply:

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
~

ase Number 59499 Client Name:

(b)(e)

(b)(6)
ntact Date: 5/14/2008
Clinical Provider:
- - - - - - - - - - - - - - - - + - - - · - - - - - - - - · - · - - · - - - - - . -·
ime Spent: 0.25
Type of Contact:
I

~ollateral

Contact:
Summary of Contact:
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.

I

(b)(6)

Date of Signature: 5/19/2008

.mil/components/forms/PrintAIIForms.aspx

1/7/2011

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~AP Clinical Contact Note
ase Number 59499 Client Name:

(b)(6)

. + - - - - - - - - - - - - - - - - - - . - - - - - - - - - - - - - - - - - - - - ----,
(b)(6)
Clinical Provider:
Contact Date: 312612008
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.
Signature of Provider:

(b)(6)

Date of Signature: 3/26/2008

.mii!componentstforms/PrintAl!Forms.aspx

1/7/2011

Page 3 of 12

; FAP Clinical Contact Note
. Case Number 68173 Client Name:

(b)(6)
-

Contact Date: 1/5/2009

Clinical Provider:

Time Spent: 0.5

Type of Contact: Phone

·---

Collateral Contact:
Summary of Contact:
18 December 2008
M for SM to prov1de documentation.
January 2009
(b)(6)
037- SM@
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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• FAP Clinical Contact Note
· Case Number 68173 Client Name:

(b)(6)

\ Contact Date: 11/19/2008

Clinical Provider:

. Time Spent: 1

Type of Contact: Other

(b)(6)

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)

(b)(6)

1otifled me that
called her asking why I recommended a 52 week group for SM.
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

·~ignature of Provider:

(b)(6)

Date of Signature: 12/1712008

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, Case Number 68173 Client Name:

(b)(6}

.

' Contact Date: 10/8/2008

Clinical Provider

Time Spent: 1

(b)(6)

Type of Contact: Other

· Collateral Contact:
·. Summary of Contact:
, 6 October 2008
(b)(6}
to determine if he has been sentenced to DVRP.
M for SM@
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

(b}(6}
(b}(6}
015- LM for
and
400 - Case to CRC
(b}(6}
CMD present.
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:

!!Contact Date:
!~/20/2009
~rovider's

arne:
(b )(6)

(b)( 6 l

(b)(6)

Appointment Administration:
Administrative Notes:
(b)(6)
ADM is currently
Status update per TC with
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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t:ase Number 74016 Client Name:

(b)(6)

Contact Date: 2/19/2010

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

(b)(6)

-

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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=AP Clinical Contact Note
6

•l:ase Number 74016 Client Name:

(bl< l

Contact Date: 9/30/2009

Clinical Provider: .

irime Spent: 0.25

Type of Contact: Email

(b)(6)

-

~ollateral

Contact: GOVERNMENT AGENCY/ORGANIZATION
~ummary of Contact:
·Barbara,
~VM has been separated from naval Service.

W/R

(b)(6)

~FAR

ss BOXER
1
6
(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

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;ignature of Provider:

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(b)(6)

Date of Signature: 9/30/2009

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ase Number 99118 Client Name:

~ ontact Date:

7/12/2010

Clinical Provider:

; ime Spent: 0.25
~ ollateral Contact:

(b)(6)
(b)(6)

Type of Contact: Phone
GOVERNMENT AGENCY/ORGANIZATION

ummary of Contact:
C to ADM to see if he has completed his 26 weeks out in the community. ADM stated that he fimshed his classes and
l~puld drop off the sheet from his group leader to show that he has completed his treatment. Let ADM know that as soon as I
19 st til at paperwork I will be able to close his case as treatment resolved.

I ignature of Provider:

(b)(6)

Date of Signature: 7/12/2010

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ase Number 99118 Client Name:

(b)(6)

:~ ontact Date: 6/9/2010

Clinical Provider:

r ime Spent: 1

Type of Contact: In Person

(b)(6)

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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~ ase Number 99118 Client Name:
I ontact Date: 6,7/2010
r ime Spent: 0.25

(b)(6)

Clinical Provider:

(b)(6)

Type of Contact: Phone

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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( ase Number 99118 Client Name:
on tact Date: 5/26/201 0

(b)(6)

Clinical Provider:

: ime Spent: 0.25
~

(b)(6)

Type of Contact: Phone

ollateral Contact:

! ummary of Contact:
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.
1

r ignature of Provider:

!If- umber

!Appendage Note

(b)( 6)

Date of Signature: 5/26/2010

!Provider's Name

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----

\b)(6)

!Date

5/26/201 0 2:00:00 PM

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:ontact Date: 3/10/2010

(b)(6)

Clinical Provider:

ime Spent: 0.5

(b)(6)

Type of Contact: Phone

: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.

i ~ignature of Provider:

(b)(6)
..........

Date of Signature: 311 0/2010

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~ AP Clinical Contact Note
pase Number 99118 Client Name:

(b)(6)

Clinical Provider:

Contact Date: 1/8/2010

(b)(6)

Type of Contact: In Person

ime Spent: 1

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
:iummary of Contact:
Met with client to go over CRC treatment recommendations and to get progress of his 52 week DV groups. Client brought in
srgned form from his group leader showing that he has attended 5 out of 52 weeks at this time. Let chen! know that after 26
. eeks that he completes out in the community we would be able to close his case here. Let hrm know that I would need a
· regress report of how many classes he has attended every 90 days for the CRC review at that time. ADM stated that
· ~rrently t11m and his wife are still living separately and stated that he has been having concerns with her continuing to call
. im at work and try to harass hirn and talk to hrs commanding officers. Discussed wrth client possible solutions and gave
• ient referral to navy legal and looking into getting a restraining order if the harassment continues.

1

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(b)(6)

Date of Signature: 1/8/2010

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FAP Clinical Contact Note
Case Number 99118 Client Name:

(b)(6)

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ontact Date: 1fl/201 0

Clinical Provider:

(b)(6)

Type of Contact: Phone

• ime Spent: 0 5

I ollateral Contact: GOVERNMENT AGENCY/ORGANIZATION

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
)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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(b)(6)

Date of Signature: 1;7!2010

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· FAP Clinical Contact Note
Case Number 99118 Client Name:

(b)(6)

-----··-·

Contact Date: 11/13/2009

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

(b)(6)

. r-------------------------------------~r---------------------------------------~
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 .

. ~----------~------------------------~------------------------------------~
Date of Signature: 11/13/2009

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FAP Clinical Contact Note
Case Number 99118 Client Name:

'

(b)(6)

Contact Date: 11/10/2009

Clinical Provider:

Time Spent: 025

Type of Contact: Phone

(b)(6)

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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Signature of Provider:

(b)(6)

Date of Signature: 11/10/2009

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FAP Clinical Contact Note
Case Number 99154 Client Name:

(b)(6)

Contact Date: 12/3/2010

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

(b)(6)

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summary of Contact:
CM called this client to get a copy of her final progress report from her DVRP group 1n the communtty showing she
completed all 52 groups. CM wants th1s document because 11 will support the case being closed as resolved.

Signature of Provider:

(b)(6)

Date of Signature: 12/3/2010

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FAP Clinical Contact Note
Case Number 99154 Client Name:

(b)(6)

---

(b)(6)

Clinical Provider:

Contact Date: 8/27i201 0

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Time Spent: 0.25

Type of Contact: Phone

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.

(b)(6)

Signature of Provider:
~-~

Date of Signature: 8/27/2010

--··~--·-·-·-

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FAP Clinical Contact Note
Case Number 99154 Client Name:

(b)(6)

··-

Contact Date: 4/30/2010

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

(b)(6)

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summary of Contact:
CM called th1s client to check in with her. Client reported she is continuing to make progress on 11er DV groups. Ghent
reported she ts on group 22 bf 56. Client satd she is currently tn Flonda with 11er mother, sister, and father visittng and
dropprng her baby off. Client satd she has given her mother power of attorney and plans to leave her baby with her family
until "thtngs settle down." Client said, "I have been carrying for her by myself for 5 months, it will be good for her to be with
family."
(b)(6)
made a false allegat1on of child abuse (neglect) to CPS. Ghent said (b)(6)
Client reported her ex-boytnend
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.

Signature of Provider:

(b)(6)

Date of Signature: 4/30/2010

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Collateral Contact Note
Case Number 99154 Client Name:

(b)(6)

IClinical Provider

Contact Date: 2124/2010

(b)(6)

ITime Spent: 0.25

CO:
Contact Name:

(b)(6)

I

Collateral Contact: GOVERNMENT
Type of Contact: In Person
AGENCY/ORGANIZATION
Contact Notes:
Offender dropped off l1er domestic violence program update for her 90 day review. Report showed client has attended 10
sessions. and therefore has 42 remaining
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Signature of Provider:

(b)(6)

IDate of Signature: 2124/2010

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Case Number 99154 Client Name

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Contact Date: 2/12/2010

(b)(6)

Clinical Provider:

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(b)(6)

Time Spent: 0.25

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Contact Name:

(b)(6)

IType of Contact: In Person

Collateral Contact:

Contact Notes:
Per CM request, CM received a progress report stating her attendance in the 52 week domestic Violence program. Her
facil1tatorgave the (b)(6) pos1t1ve remarks about her partiCipation in the group.

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Signature of Provider:

(b)(6)

j Date of Signature:

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F~P Clinical Contact Note
(b)( 6 )

C :tse Number 108326 Client Name:

------------~-----------

Contact Date: 12/14/2010

Clinical Provider

T me Spent: 0.25

Type of Contact: Email

(b)(6)

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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( ase Number 108326 Client Name:
( ontact Date: 12/3/201 0
-~ rovider's Name:
{b){6)

{b){6)

Appointment Administration:

(b)( 6)

Administrative Notes:
ADM was transferred to the
(b )(6)
continuing treatment when rmurns.

and is now deployed for 6-7 months so will be

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Case Number 108326 Client Name:

(b)(6)
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ontact Date: 11/15/2010

Appointment Administration:

rovider's Name:
(b)(6)

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Administrative Notes:
TC to ADM to check in. Left message for him to call back this CM as soon as he can to let me
know where he is at this time in his recommended treatment.

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C~se Number 108326 Client Name:

ICpntact Date: 10/21/2010
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(b)(6)

(b)( 6)

Appointment Administration:

(b)(6)
Administrative Notes:
TC to ADM to check in to see how things are going and how far along he is on his
recommended treatment.

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clinical Contact Note

c ~se Number 108326 Client Name:
c pntact Date: 8/26/2010
T me Spent: 0.25
N mber of Individuals Seen: 1

(b)(6)

jType of Contact: Phone

T pe of Counseling Group:

jType of Session: Couple
ssion Notes:
p one consult w1th SM re: his status for 90 day Rev. Client is 3.5 months into his 52 week civilian DV group and has
re reived a 4.5/5 grade for progress, attendance, etc. He is doing well and IS benefiting immensely from the group.

s

p an Status
D i<lgnostic Impression
R commended Referrals:
In House FFSC:

IExternal Military:

IExternal Civilian:

jTri-Care:

IGNATURES
S gnature of Provider:
S gnature of Supervisor:

(b)(6)
(b)(6)

Date of Signature: 8/26/2010
Date of Signature: 10/5!201 0

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l::ase Number 111035 Client Name:

(b)(6)
(b)(6)

Contact Date: 5/26/2010

Clinical Provider:

ifime Spent: 1

Type of Contact: In Person

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

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(b)(6)

Date: 10/30!2007

Clinical Provider:

Time Spent: 0.25

(b)(6)

of Contact: Phone

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)

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Note
(b)(6)

Clinical Provider:

(b)(6)

of Contact: Phone

of Signature: 2/8/2008

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Contact
(b)(6)

Time Spent: 0.25
Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summary of Contact:
Received case as a transfer today from previous Case Manager

(b)(6)

(b)(6)

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Contact
Case Number 14721 Client Name

(b)(6)

Contact Date: 5/7/2007
Time

Provider:

(b)(6)

0.25

Collateral Contact: GOVEFiNMENT f,GENCY!ORGANIZATION
Sumrnary of Contact:
Email from CFAR indicates that
DVRP sessions attended.

(b)(6)

·will be separat1ng /rom the Navy in one month She has not providod the

(b)(6)
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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)
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I wanted to let you know that I will be leaving rny pos1t1on at FAP and taking a new JOb at

you ploaso assrst me with t11e follo·,v1ng:
(b)(6)
. I nuecl to know iht) # of DVRP sessions st1e has attondod. ·n,e last I heard was t11at you were tryn1g to
ltlrs 1nfo frorn tHe!.

(b)(6)

Signature: 5,?/2007

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Ill~

(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.
·,vJII onsum that SM contacts this CM.

(b)(6)

Signature: 4/9/2007

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12/27/20 I 0

Page ll of 21

(b)(6)
(b)(6)

Contact: GOVEflNMENT AGa~CY!ORGANIZATION
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
attended 16 court mandated DVRF' classes

emi:lil

sene! 111 Marcil. Perhaps I can close tllis caso on

(b)(6)

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

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(b)(6)

Clinical Provider:

Contact Date; 12/2l/2006

(b)(6)

of Contact; Email

Tfrne

Collateral Contact:
Sununary of Contact:
EM/\IL FlESF'ONSE FROM CFAR
(b)(6)

MSC USN

V\fecJnp;::;d::w rlrornmber 20 2006 11:48 PM
(b)(6)

'

HE· DV clnsses
t)een to every class oxcopl the ones I've rn1ssed duo to being underway. This com1ng V\lednesc!ay I can get you a report
ttle class and brin(J it to you

(b)(6)

of Signature: 12/21/2006

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(b)(6)

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(b)(6)

Provider.

(b)(6)

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.
R/A F\EDUCED FFiOM MH TO M.

(b)(6)

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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.

(b)(6)

ill t 1

of Signature: 6/14/2006

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Note
(b)(6)

Provider:

(b)(6)

Collateral Contact: GO\!EF1NMEf\IT AGEI\JCY/ORGANIZATIOt\1
Summary of Contact:
Vanous calls nnd emails to CFAR and Le~)al Off1co to learn of court outcome for
(b)(6)

Legal Office,

1S

requesting that SM bring in cJocurnentatlon of her court outcome.

(b)(6)

ll

(b)(6)

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6/7/2006

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Page 21 of 21

n

Contact Note

Number 14721 Client Name:

(b)(6)

Clinical Provider:

13/2006

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
states tilat r'\DF

IS

stating her act1ons wme in self-defense

(b)(6)

htq

of Signature: 4/13/2006

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ltAP Clinical Contact Note

(b)(6)

----

Clinical Provider:

tontact Date: 1/28/2010

(b)(6)

Type of Contact: Email

ime Spent: 0.25

i f-OIIateral Contact:
ummarv of Contact:
(b)(6)
j

was dJschar~ed from the Navy around the time that I was
(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)

~'ng oumO'ec w'lh

\

(b)(6)

I

qmmand Master Chief
SS ANTIETAM CG54
fflce:(619) 556-4497
(b)(B)
mail
~mail

(b)(6)

~IGNATURES

i

(b)(6)

: ignature of Provider:

Date of Signature: 1/29/2010

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FAP Clinical Contact Note
Case Number 50539 Client Name:

(b)(6)

Contact Date: 1/28/2010

Clinical Provider:

~

Type of Contact: Email

ime Spent: 0.25

(b)(6)

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
Vlanager: (b)( 6)

(b)(6)

Cate. 14 Oct 09 Client's Name:

Croup Name: Cypress Group Leader(s):

(b)(6)

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

~FECT THERAPEUTIC CONCERNS
beat xxx Incident of Re-abuse
Cjuarded Suicidal
~sentful Increased Risk of Re-abuse
lm x Hostile, Aggressive Behavior
ustrated x Increased Depression

i""""'

appropnateloccea,ed
Other
at None x

Stm"

t

xious
nfident
gretful

~ther
l

~ditional Comments or Closing Summary:
ent participated actively in the group discussion. He shared his frustrations and stress related to his work. Group provided

f( edback and coping strategies were discussed.
P an Status

'

I Ciagnostic Impression

_:d

., '

"'>''''

<

' , •. '

,,.

· .. •.·

ecommended Referrals:
I -House FFSC:

IExternal Military:

IExternal Civilian:

ITri-Care:

. :>IGNATURES
; ignature of Provider:

(b)(6)

I Date of Signature: 10/19/2009

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(b)(6)

qase Number 50539 Client Name:
Sfntact Date: 9/9/2009

jType of Contact: In Person

Time Spent: 1.5
~mber of Individuals Seen: 1
Type of Counseling Group: Offender Group

jType of Session: Group

~ssion Notes:
oup Note/Participation Form
(b)(6)

crte: Sep 9, 09 Client's Name:

id oup 1'-Jame: Cypress Group Leader(s):

Manager (b)( 6 )
(b)(6)

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
rvtotivation for Change 3
lflSight & Self Awareness into
srhavior

3

~spectful attitude 4
erall Participation 3

~FECT
THERAPEUTIC CONCERNS
U beat xxx Incident of Re-abuse
. arded Suicidal
R sentful Increased Risk of Re-abuse
C lm x Hostile, Aggressive Behavior
Fi ustrated Increased Depression
R flective x Increased Stress
1r appropriate Other
F1 at None x
A gry
d
A 1xious
C nf1dent
R gretful
0 her
l
.l

s

Atditional Comments or Closing Summary:
T. is was client's first week back in group since deployment in Nov 08. Client was introduced to the group and shared his
stbry. Client adjusted quickly and took part in the discussion regarding FOO differences and their effect on relationships.

P~n Status

,

..

i :'

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(:.

D agnostic Impression
R commended Referrals:
In House FFSC:

IExternal Civilian:

!External Military:

ITri-Care:

~IGNATURES

S gnature of Provider

(b)(6)

I Date of Signature: 9/15/2009

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Thanks for the update. I'll wait to hear from you re: his discharge.

9.

(b)(6)

!
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Ftom.
Sfmt: 1- noav. JUIV

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(b)(6)
j

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(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)

I

Up0 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:

$
rr

ot

(b)(6)

'"'"·'""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)
nt: 1nursdav. Julv 30. 2009 10:40
T :
(b)(6)
0:
(b)(6)
S bwcc ro11ow up on t-Al-' case

S

(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 100011r0. 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:
i

(b)(6)

IClinical Provider:

Qontact Date: 7/30/2009

'

(b)(6)

ITime Spent:

0.25

¢oNTACT
!

(b)(6)

Cpntact Name:

A~~lateral Contact: GOVERNMENT

ENCY/ORGANIZATION
~pntact Notes:
Ernail send to CMC with SM cc'd.
i

IType of Contact: Email

(b)(6)

would be able to
l~ot1ced on the ship locator that the ship is back so wanted to follow up to see when
(b)( 6)
r turn to the Men's group. He has completed 7 of 16 groups. and is in group Cypress which meets every Wed from 10001~ 30. I have CC'd him as well to remind htm of the meeting times. Please let me know when he will retum.
l

R\

(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

S gnature of Provider:

(b)(6)

IDate of Signature: 7/30/2009

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Cj)se Number 50539 Client Name:
Qontact Date:
7ff30!2009
Firovider's Name:
(b)(6)

(b)(6)

Appointment Administration:
Administrative Notes:
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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(b)( 6 l

c+se Number 50539 Client Name:
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

D,te 10/8/08 Client's Name

(b)( 6)

Grpup Name: Cypress Group Leader(s):

__

·Case Manager: (b)(6)

&)ll.P)

s+ston #

f.
A~eptance Of Responsibility 3

(1 none; 2"rarely;3=sometimes;4"often:5=very often)

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

Af4F~· ECT THE RAP- EUTIC CONCERNS
1

U eat Incident of Re-abuse
G arded Sutcidaltty
RE'fentfullncreased Risk of Re-abuse
C~m x Hostile, Aggressive Behavior
Fr,~strated Increased Depression
Reflective Increased Stress
ln~ppropnate Other_ _ _ _ _ _ __
Fl* None
Angry
Sa~
Ankious
Cobfident
Regretful
Ot~er

,,

Arll1illnn::<l

r.nmm,:>nt~
(b)(6)

nr r.ln.,inn

~'Jmmary: SM partictrated in group discussion

Pl~n Status
I

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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(b)(6)

C~se Number 50539 Client Name:
Cbntact Date: 10/1/2008
Time Spent 1.5
NLmber of Individuals Seen: 1

j Type of Contact: In Person

Ttpe of Counseling Group: Offender Group
-Stssion Notes:
Gtoup Note/PartiCipation Form

!Type of Session: Group

D~te

1'""

Case Manager:(b)( 6)

(b)(6)

10/1/08 Client's Name:

l

Nam" Cypre" Groop Leader(')

(b}l!.)

S ssion # 3
·i

(1l=none: 2=rarely;3"-'sometimes;4=often;5=very often)

I

A~ceptance Of Responsibility 3
Pprsonal Disclosures 3
E;~pathy for child and/or others 3
1\ owledge & Understanding of
ffiective Anger Management Strategies 3
t1valion for Change 4
ighl & Self Awareness 1nto
Bf-havior

3!
RPspectful attitude 3
CjvP.rall Participation 3
JFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
<l.Jarded Suicidality
~sentful Increased Risk of Re-abuse
~lm xHostile, Aggressive Behavior
ustrated Increased Depression
~flect1ve Increased Stress
appropriate Other
at None
Atlgry

~dXIOUS

Q:Jnfident

~gretful
her

~~ditional Comments or Closing Summary:

SM talked about his anger and coping mechanism.

(b)(6)

' Status
P~an

,, ,,

~iagnostlc Impression
~commended

·t.,'

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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~~linical Contact Note
( ase Number 26353 Client Name:

(b)(6)

ontact Date: 1/17/2008
!Type of Contact: In Person

ime Spent: 1 .5
umber of Individuals Seen: 1
1

!Type of Session: Group

ype of Counseling Group: Offender Group
ession Notes:

' :iroup Note/Participation Form
pate: 1/17/08 Client's Name:

(b)(6)

, proup Name: FALCON Group Leader(s):

Case Manager:(b)(B)

(b )[t:;)

:;ession il 13
1--ontent of Group:
1 =none; 2=rarely;3=somelimes:4=often;5=very often)
'\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

f:\FFECT THERAPEUTIC CONCERNS
~pbeat Incident of Re·abuse
Guarded Suicidality
Resentful Increased Risk of Re-abuse
Calm X Hostile, Aggressive Behavior
rustrated Increased Depression
Reflective Increased Stress
nappropriate Other _ _ _ _ _ _ __
Flat None
it>-ngry

Sad
Anxrous
Confident
Regretful
Other
Additional Comments or Closing Summary:
(b)(6) was quiet, attentive and provided some constructive feedback to others.

I
(b)(6)
(Revised 7/2006 (.15){0J
':; Plan
--·c· n; ~·~-----------------------------------1
Status
'"::u
lW•l•<'.' :·, C>-llf!lC!li

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

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~linical Contact Note

(b)(6)

: ~ase Number 26353 Client Name:
; pontact Date: ,1/10/2008

ime Spent: 1.5
umber of Individuals Seen: 1

!Type of Contact: In Person

ype of Counseling Group: Oflender Group

!Type of Session: Group

pession Notes;
p;roup Note/Participation Form
(b)(6)

pate: 1110/08 Client's Name:

proup Name: FALCON Group Leader(s):

Case Manager (b)( 6)

l.,b} (\o)

peSS/011 # 12

pontent of Group:

1=none; 2=rarely;3=sometimes,4=olten;5=very often)
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
' FFECT THERAPEUTIC CONCERNS
pbeat 1nc1dent of Re-abuse
uarded X SUicidality
esentful Increased Risk of Re-abuse
aim X Hostile, Aggressive Behavior
rustrated Increased Depression
eflective Increased Stress
j appropnate Other~------­
jf lat r~one
IJ ngry
I~ ad

i(nXIOUS

j( onfident

If egretful
)( ther
\

I~ kJditJonal Comments or Closing Summary:
(b)(6)was quiet, attentive and provided some constructive feedback to others.

I
1 ev1sed 7/2006

(b)(6)

(.b~J

--------------------------------------------------------------------1

Pan Status

,-d[('/(.'

I

'

0 agnostic Impression
R~commended

Referrals:

1r House FFSC:

!External Military:

!External Civilian:

jTri-Care:

~ IGNATURES
S gnature of Provider

(b)(6)
J

Date of Signature: 1i15/2008

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·Collateral Contact Note
(b)( 6 )

Case Number 26353 Client Name:

j Clinical

' Contact Date: 12115/2007

Provider

(b)(6)

j Time Spent: 0.25

CONTACT
Contact Name:

(b)(6)

Collateral Contact:

/Type of Contact: Email

Contact Notes:
(b)(6)

II

here from FRCSouthwest formerly AI MD North Island. I have an upcoming CRC review on the 20th for now (b)( 6)
I found out today he made his court appearance yesterday and was awarded probation for 3 years and
eommunity service hours. He also was starting his group Induction class this morning.
ust wanted to touch base wlth you before the Crc since I will be coming 111 from leave to attend.
(b)(6)

1

(b)(6)

-·-~----------------------------------~

SIGNATURES

:;ignature of Provider:

(b)(6)

j Date of Signature: 2n12007

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. Clinical Contact Note
(b)(6)

:Case Number 26353 Client Name
. Contact Date: 12f7/2007
·. Time Spent: 1.5
1

1

!Type of Contact: In Person

Number of Individuals Seen: 1
jType of Session: Group

ype of Counseling Group: Offender Group

:!Session Notes:
f:;roup Note/Participation Form
Date: 11/29/07 Client's Name:

(b)(6)

~roup Name: FALCON Group Leader(s)

Case Manager:(b)( 6 )

(b)( b)

pession II 11
~ontent of Group:

1;;:;none; 2==rarely:3=sometimes;4=often;5=very often)
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

II FFECT THERAPEUTIC CONCERNS
I~ pboat Incident of Re-abuse

It uarded x Suicidality
If esentlul Increased Risk of Re-abuse
I< aim x Hostile, Aggressive

Behav1or

[f ustrated Increased Depression

IF eflective Increased Stress

I appropriate Other _ _ _ _ _ _ __

IF at x None

iii 1gry
1Sf3.d

'/1 1xious
'Cpnf1dent
F egretful
C her
A ~ditional Comments or Closing Summary:
has rece1ved orders to Lemore and appears to be accepting that 11e will soon be living with CW again. He appeared
lprsmve about the move, and in particular, to being closer to hiS son.
(b)(6)

(Fevised 7/200.
Pl~n

Status

{b )(e;LL.?_)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
>(,:

iJ1;'

i

it ,:·",l;ll<'/1(

t'•!

1

i!

Diagnostic Impression
R~

commended Referrals:

In House FFSC:

!External Civilian:

!External Military:

_ITri-Care:

E GNATURES
s,ignature of Provider.

IDate of Signature: 12/7/2007

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FAP Clinical Contact Note
Case Number 26353 Client Name:
, Contact Date: 11/30/2007

(b)(6)
(b)(6)

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

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

Received return call. SM stated having been underway and then on leave.
He stated he will be at group next week.

JProvider's Name

(b)(6)

Date

11/30/2007
5:19:00 PM

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Clinical Contact Note
(b)(6)

Case Number 26353 Client Name:
Contact Date: 11/29/2007

jType of Contact:

• Time Spent: 0
Number of Individuals Seen: 0

!Type of Session: Group

Type of Counseling Group: Offender Group
Session Notes:
Group Note/Partrcrpation Form
Date: 11/29/07 Client's Name:

(b)(6)

' Group Name· FALCON Group Leader(s)

Case Manager (b)( 6 )

(.b)~)

Sessron # Absent-Excused
• Content of Group:
. (1 =none; 2=rarely;3=sometimes;4=often:S=very often)

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
P,FFECT THERAPEUTIC CONCERNS
Upbeat lncrdent of Re-abuse
3uarded Suicrdaltty
Resentful Increased Rrsk of Re-abuse
~aim Hostile, Aggressive Behavior
rustrated Increased Depression
flellecttve Increased Stress
nappropriate Other_~,--~-~~--­
lat f>Jone
f'\ngry
pad
nxrous
1--onfident
~egretful

Pther
r-dditional Comments or Closing Summary.
(b)(6)

(Bevrsed 7/2006
ian Status

L\2-,~.).: .l.:~G;. .~o;. ·

------------------------------/

iagnostic Impression

!-~' ' '. '

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

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Clinical Contact Note

ur 37

(b)(6)

Case Number 26353 Client Name:
Contact Date: 11115/2007

jType of Contact:

Time Spent: 0
Number of Individuals Seen: 0

)Type of Session: Group

Type of Counseling Group:
Session Notes:
Group Note/PartiCipation Form
Date: 11/15/07 Client's Name.

(b)(6)

Group Name: FALCON Group Leadens). ·

Case Manager: (b)(B)

(.b) (LP)

Session# Absent-Excused
Content of Group

(1 =none, 2=rarely:3=sometimes;4=often:5=very often)
: 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
t>,FFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Suarded Suicidality
Resentful Increased Risk of Re-abuse
~aim Hostile, Aggressive Behav1or
rustrated Increased Depression
'ieflective Increased Stress
nappropnate Other__________ _
·/at None
1,ngry
pad
nxious
onfrdent
I eg1etful
)!her
' ddi!ional Comments or Closing Summary:
(b)(6)

!

( Rev1sed 7/2006

(b) lb)
\l:;.

F ian Status

Ciagnostic Impression

' ' '- , '

I

!

~

:· ... -.

ecommended Referrals:
I -House FFSC:

!External Military:

!External Civilian:

jTri·Care:

• ;IGNI\TUFlES

S ·gnature of Provider:

(b)(6)

j Date of Signature: 11/19/2007

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Clinical Contact Note
(b)(6)

Case Number 26353 Client Name:
Contact Date: 11/13/2007

jType of Contact:

Time Spent: 0
Number of Individuals Seen: 0

!Type of Session: Group

Type of Counseling Group: Offender Group
Session Notes:

. Group Note/Part1c1pat1on Form
Date. 1 1/8/07 Cl1ent's Name:

(b)(6)

G1oup Name: FALCON Group Leader(s):

Case Manager:(b)( 6)

(b)[{p)

Sess1on !I Absent-Excused
Content of Group:
(1 =none; 2=rarely;3=sometlmes;4=often;5:::very often)
Acceptance Of Responsibility
Personal Disclosures
Empathy for child and/or others
. Knowledge & Understanding of
Effective Parent1ng Strategies
· Motrvation for Change
' Insight & Self Awareness into
·Behavior
Respectful attitude
pverall Participation

I

~FFECT THERAPEUTIC CONCERNS
pboat Incident of Re·abuse
3uarded SUJcidallty
iesentful Increased Risk of Re·abuse
aim Hostile, Aggressive Behavtor
·rustrated Increased Depress1on
ieflect1ve Increased Stress
lt"Jappropnate Other__
Ia! None
ngry
ad
nxious
onfident
jf egJetlul
~~ ther
I•
jl dditional Comments or Closing Summary

(b)(6)

.

External Military:

' .,,,

External Civilian:

Tri·Care:

E !GNJ\TUFlES

S gnature of Provider:

h

tr\

(b)(6)

Date of Signature: 11 i 13/2007

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Form~

~~linical Contact Note
( ase Number 26353 Client Name:

j

I

(b)(6)

ontact Date: 1/17/2008
!Type of Contact: In Person

ime Spent: 1.5
umber of Individuals Seen: 1

!Type of Session: Group

ype of Counseling Group: Offender Group
ession Notes:
roup Note/Partrcrpation Form

(b)(6)

Date. 1!17/08 Client's Name:

proup Name: FAlCON Group Leader(s)

Case Manager: (b)( 6 )

(F )(lp)

ession 11 13
onlent of Group:
1 =none: 2=rarely;3=somelimes:4=often;5=very often)

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
~FFECT THERAPEUTIC CONCERNS
Wpbeat Incident of Re-abuse
f:;uarded Surcidality
Resentful Increased Risk ol Re-abuse
Calm X Hostile, Aggressive Behavior
. rustrated Increased Depression
Reflective Increased Stress
nappropriate Other _ _ _ _ _ _ __
; Flat None
:[Angry
Sad
lA.nxrous
:Confident
; Regretful
Other

Additronal Comments or Closing Summary:
(b)(6) was quiet, attentrve and provrded some constructrve feedback to others.
(b)(6)

(Revised 7/2006

{.b'X{-)

· Diagnostic Impression
' Recommended Referrals:
In-House FFSC:

!External Military:

!External Civilian:

lrri-Care:

SIGNATURES

·r---------------------------------------.---------------------------------------~

, Signature of Provider:

(b)(6)

I Date of Signature:

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Page 13 of 37

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~linical Contact Note

(b)(6)

Case Number 26353 Client Narne:

c~(o~n~t~a~ct~D~at~e~:~1/~1~0~/2~0~0~8----------------------------------~=---~~~~~~~~--------------j
1~Time
Spent: 1.5
jType of Contact: In Person
umber of Individuals
ype

Seen: 1
!Type

of Counseling Group: Offender Group

of Session: Group

:session Notes:
;::>roup Note/Participation Form

:::ase Manager(b)( 6)

(b)(6)

bate: 1110/08 Client's Name:

proup Name: FALCON Group Leader(s):

{h). {y;- J
~

pessron # 12
pontent of Group
i =none, 2=rarely;3=sometrrnes,4=oflen;5=very otten)

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
FFECT THERAPEUTIC CONCERNS
ptJeat 1nc1dent of Re-abuse
uarded X SUJcidality
esentful Increased R1sk of Re-abuse
IC aim X Hos!Jie, Aggressive Behavior
IF rust rated Increased Depression
IF eflective Increased Stress
I appropriate Other~-~---~-­
IF !at None
ngry

IJ

~~ad

,t rlXIOUS
Conf1dent
F egretful
C !her
.AkJdJtJonal Comments or Closing Summary:
(b)(6) was qUiet. attent1ve and provided some constructrve feedback to ot11ers

I
if

8VISed

(b)(6)

7/2006;,

Pan Status

(p)~)

~--~---------------------------------------------------------------------1
..

: ,.

.,, .::

\it(

f,,_,,:'

.·1;

.,,,,

-';-·',1

D agnostic Impression
A9commended Referrals:
lr House FFSC:

!External

! IGNJ.\.TURES
S gnature of Provider:

(b)(6)

Military:

)External Civilian:

jTri-Care:

I

Date of Signature: 1115/2008

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Page 16 ol37

ollateral Contact Note
ase Number 26353 Client Name:
Clinical Provider:

i 2/15/2007

(b)(6)
(b)(6)

Time Spent: 0.25

(b)(6)

Type of Contact: Email

ollateral Contact:

~)?")tes:
6
(b)( )

here from FRCSouthwest formerly AIMD North Island. I have an upcoming CRC review on the 20th for now(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.

/'

(b)( 6 )

1
·--~)(""1----------------------------------i

SIGNATURES

ignature of Provider:

(b)(6)

Date of Signature: 2/7/2007

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Clinical Contact Note
(b)(6)

Case Number 26353 Client Name:
Contact Date: 12!7!2007

!Type of Contact: In Person

Time Spent: 1.5
Number of Individuals Seen: 1

!Type of Session: Group

Type of Counseling Group: Offender Group
• Session Notes:
Group Note/Participation Form

(b){6)

pate: 11/29107 Client's Name:

proup Name: FALCON Group Leader(s)

::ase Manage~b)( 6 )

(b) ( (p)

;:)ession II 11
~ontent

of Group:

1 :=none; 2=rarely:3=some!Jmes:4=o1ten;5=very often)
~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

FFECT THERAPEUTIC CONCERhiS
pbeat Incident of Re-abuse
uarded x Su1cidality
F esentful Increased Risk of Re-abuse
Caim x Hostile, Aggressive Behav1or
F ustrated Increased Depression
F ellective Increased Stress
I appropriate Other___~------~
F at x ~-Jone

.trgry
!Sad

lA IXIOUS
IF

!Confident
f.gretful
her

IC

A~d1tional Comments or Closing Summary:
(b)(6) has rece1ved orders to Lernore and appears to be accept1ng that he will soon be living with CW ugain. He appeared
ptsJtJve about the rnove. and 1n particular, to being closer to h1s son.

(b)(6)
(F evised 7/200f:{

lb)~')

Plan Status
Dipgnostic Impression
R commended Referrals:
In House FFSC:

!External Military:

!External Civilian:

jTri-Care:

$.GN/l,TURES
Signature of Provider:

hlt

(b)(6)

IDate of Signature: 12!7/2007

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FAP Clinical Contact Note
Case Number 26353 Client Name:

(b)(6)
(b)(6)

Contact Date: 11/30/2007

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

--~--------l

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:

IIPPEND/~GE

(b)(6)

Date of Signature: 11/30/2007

NOTE

Number Appendage Note

Received return call. SM stated having been underway and then on leave.
He stated he will be at group next week.

!Provider's Name
(b)(6)

Date

11/30/2007
5:19:00 PM

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I

IClinical Contact Note

(b)(6)

Case Number 26353 Client Name:
Contact Date: 11/29/2007

!Type oi Contact:

iime Spent: 0
Number of Individuals Seen: 0

!Type of Session: Group

Type of Counseling Group: Offender Group
Session Notes:
Group Note/Partrcrpation Form
Date: 11/20/07 Client's t\lame

(b)(6)

Group Name· FALCON Group Leader(s): ··

Case lv1anager (b)( 6)

Cl?)~)

Sosswn II Absent-Excused
Content of Group:
( 1=none: 2=rarely;3=sometimes;4=often:5=very often)

Acceptance Of Responsibrlity
Personal Drsclosures
Empathy lor child and/or others
f\nowledge & Understanding of
: Effect1ve Parentmg Strategies
tv1ot1vat1on tor Change
lns1ght & Self Awareness rnto
. Behav1or
' Respectful att1tude
. Overall Participation

I

AFFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
3uarded Suic1dalrty
Resentful Increased R1sk of Re-abuse
~aim Hostile, Aggressive Behavior
rustratod Increased Depressron
Refloctrve Increased Stress
nappropnate Other_~·---.------lat None
t'ngry
pad
t"\nXIOUS
~onl1dent

~egretful
pther

dditional Comments 01 Closing SLJmmary.
(b)(6)
ev1sed 712006.'

Jan Status
iagnostic Impression
ecommended Referrals:
External Military:

External Civilian:

Tri-Care:

:>IGNATURES
ignature of Provider:

(b)(6)

Date of Signature: 11/30/2007

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Clinical Contact Note
(b)(6)

Case Number 26353 Client Name:

---------------------,

Contact Date: 11 !15/2007
!Type of Contact:

Time Spent: 0
Number of Individuals Seen: 0

jType of Session: Group

Type of Counseling Group:
Session Notes:
Group Note/Participation Form
Date: J 1/15i07 Client's Name:

(b)(6)

Group Name FALCON Group Leader(s)·'

Case Manager (b)( 6 )

(\a)(~)

Session II Absent-Excused
Content of Group·
(1 ::;none, 2=rarely:3=sometimes;4=often:5=vef)' often)
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
1!\FFECT THERAPEUTIC CONCERNS
Wpbeat Incident of Re-abuse
~uarded Suicidality
Resentful Increased Risk of Re-abuse
Calm Hostile, Aggressive Behav1or
rustrated Increased Depression
:'lellective Increased Stress
nappropnate Other_ _ _ _ _ _ _~lat None
ngry

ad
nxious
:onf1dent
egretful
Dther
ddrtional Comments or Closing Summary

(b)(6)

(ReVISed 7!2006:

{p)(4:>)

[F ian Status

--------------------------------------------------------------------1

ICiagnostic Impression
"commended Referrals:

I -House FFSC:

!External Military:

!External Civilian:

I_Tri-Care:

• t!GNJ\ TUFlES

S ·gnature of Provider:

(b)(6)

j Date of Signature: 11/19/2007

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Clinical Contact Note

(b)(6)

Case Number 26353 Client Name:
Contact Date: 11/13/2007
Time Spent 0

jType of Contact:

Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

!Type of Session: Group

Session Notes:
Group Note!Part1c1pa!lon Form
(b)(6)

Date. 11/8!07 Client's Name·

Case Manager:(b)(G)
----

(b)~)

Group Name: FALCOr\J Group Leader(s)
Sess1on # Absent-Excused
Content of Group:

( 1=none: 2=rarely;3=sometlrnes;4=olten;5=very often)
• 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
C..FFECT THERAPEUTIC CONCERNS
~pbeat Incident of Re-abuse
;_=;uarded Su1cidality
lesenttul Increased Risk ot Re-abuse
'aim Hostile, Aggressive Behavror
-rustrated Increased Depress1on
~eflectiVe Increased Stress
Jrapproprrate Other
lat None
ngry
ad
nxious
onfident
jf egretful
I< !her
jf dd1t1onal Comments or Closing Summary:

----

(b)(6)
( ev1sed 7/2006,,.!(blf[()

Pan Status

'

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;

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D agnostic Impression

l ::: · ; ; . : .

;

.,.!

. ·.

:·;.·,;

,:.·!' ,,,

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

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Plinical Contact Note
(b)(6)

~ase Number 26353 Client Name:
t:onWict Date: 11/1/2007

!Type of Contact: In Person

ime Spent: 1.5
Number of Individuals Seen: 1

!Type of Session: Group

ype of Counseling Group: Offender Group
pession Notes:
proup Note/Participation Form

pate: 11/1/07 Client's Name

(b)(6)

proup Name: FALCON Group Leader(s)

Case Manager (b )( 6)

(J:J) ~)

pession # Absent-Excused
pontent of Group:
1=none; 2=rarely;3=sometimes;4=often;5=very often)

[\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
1\FFECT THERAPEUTIC CONCERNS
~pbeat Incident of Re-abuse
ruarded Suicidality
~esentful Increased R1sk of Re-abuse
f.>alm Hostile, Aggressive Behavior
rustrated Increased Depression
ReflectiVe Increased Stress
~appropriate Other _ _ _ _ _ _ __
Jat None
rngry
~:>ad

rnxious
vonfldent
~egretful

f}ther
dd1tional Comments or Closing Summary:

flevised 7/200{
ian Status

{f')((;;)

--------------------------!

iagnostic Impression
ecommended Referrals:

I r-House FFSC:

!External Military:

piGNATURES
ignature of Provider

(b)(6)

!External Civilian:

jTri-Care:

I

Date of Signature: 11/2/2007

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Page 25 of'

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t;linical Contact Note
(b)(6)

pase Number 26353 Client Name:
~ontact Date: 10/25/2007

jType of Contact:

lfime Spent: 0
Number of Individuals Seen: 0
11 ype of Counseling Group: Offender Group

{Type of Session: Group

~ession Notes:
~roup Note/Participation Form
(b)(6)

pate: 10/25/07 Client's Name

~r

!::>roup Name: FALCON Group Leader(s):

'Case Manager:(b)( 6)

U:>)~;)

pess1on # Absent
pontent of Group:

i "'none; 2=rarely;3=sometimes;4=often;5=very often)
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
FFECT THERAPEUTIC CONCERNS
pbeat Incident of Re-abuse
ouarded Suicidality
esentful Increased R1sk of Re-abuse
aim Hostile, Aggressive Behavior
rustrated Increased Depression
eflec!lve Increased Stress
I ~appropnate Other_
Ia! None
ngry
ad
nxious
onf1dent
egretful
I< ther

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ddit1onal Comments or Closing Summary:

----

(b)(6)
(Revised 7/200l

IF

'(b)( b)

an Status

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I[ iagnostic Impression

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I -House FFSC:

!External Military:

!External Civilian:

fTri-Care:

piGNATUf-lES
~

ignature of Provider:

(b)(6)

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Date of Signature: 10/26/2007

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J:linical Contact Note
(b)(6)

pase Number 26353 Client Name:
f:;ontact Date: 10/18/2007
ifime Spent: 1.5
~umber of individuals Seen: 1

!Type of Contact: In Person

rrype of Counseling Group: Offender Group

!Type of Session: Group

~ession Notes:

Group Note!Partic1pat1on Form
:::ase Manager (b){G)

(b)(6)

pate 10/18/07 Client's Name

proup Name FALCON Group Leader(s).

(_.b)({{;)

~ession #Absent-Excused
~onten1

of Group:

, 1=none; 2=rarely;3=sometlmes:4=otten;5=very often)
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
~FFECT THERAPEUTIC CONCERNS
~pbeat Incident of Re-abuse
puarded Swcidal1ty
fiesenttul lncrea&ed Risk ol Re-abuse
palm Hostile, Aggressive Betlavior
!crustrated Increased Depression
Reflective Increased Stress
nappropr1ate Ottler ____ ~--·---"'lat None
!A,ngry

!Sad
lt\nxious
ponfident
!Regretful
pther
~cid1t10nal Comments or Clos1ng Summary:
---·-

(b)(6)

Revised 7/20Db

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!Pian Status

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plagnostic Impression

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fecommended Referrals:
n-House FFSC:

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•'.,;\:

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!External Military:

SIGNATURES
Signature of Provider:

'' '' .,

! '~ '; '

!External Civilian:

ITri-Care:

I Date of Signature: 10/19/2007

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Page 27

or 37

~dministrative Note
~ase Number 26353 Client Name:
~ontact Date: 10/11/2007
Provider's Name:

(b)(6)

Appointment Administration:
(b)(6)

Administrative Notes:
Case transferred to

11

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(b)(6)

12/13/2010

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All hxrns

Plinical Contact Note
(b)(6)

pase Number 26353 Client Name:
~ontact Date: I 0/11/2007

IType of Contact: In Person

ime Spent: 1.5
umber of Individuals Seen: 1

!Type of Session: Group

ype of Counseling Group: Oltender Group
:;ession Notes:
jroup Note/Participation Form
:::ase Manager:(b)( 6)

(b)(6)

)ate: 10/11/07 Client's Name:

J{0) -

3roup Name: FALCON Group Leader(s):{tb
ession .fi 10
Jontont of Group. Communication

1=none; 2=rarely;3=somelimes;4=often;5=very often)
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
FFECT THERAPEUTIC CONCERNS
pbeat Incident of Re-abuse
puarded X Suicidality
esentful Increased Risk of Re-abuse
alrn Hostile. Aggressive Behavior
rustrated Increased Depression
IF eflective Increased Stress
I ~appropnate Other
IF lat None
If ngry
IE ad
I~ nXiOUS
'c onl!dent
F egretful
lc ther
1

!/- dditional Comments or Closing Summary:
i ~ hared current struggles withrn marriage, facilitators attempted to provide feedback on ways that lle could be less critical and
J dgrnental; however he had difficult listening and at limes was guarded and defensive, but not disrespectful.
(b)(6)
(Revised 7/200f

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!External Civilian:

ITri-Care:

p1GNATUF1ES
E ignature of Provider:

(b)(6)

j Date of Signature: I 0112/2007

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IFAP Clinical Contact Note
Case Number 26353 Client Name:

(b)(6)

Contact Date: 9/28/2007

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

(b)(6)

Collateral Contact:
Summary of Contact:
TC from S) M: reports he was on duty 27Sep071herefore could not attend group. SM excused.
eader

(b)(6)

Informed group

(b (B)

SIGNATURES
Signature of Provider:

(b)(6)

Date of Signature: 9/28/2007

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Administrative Note

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Case Number 76567 Client Name:
,

Contact Date: 3/10/2009

·.

Provider's Name:
(b)(6)

'II

(b)(6)

Appointment Administration:

(b)(6)

Administrative Notes:
TC with ADM to request copy of confirmation of attendance rn 52-Week Men's Offenders
Group. ADM will fax confinnation today.

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(b)(6)
..

~~

(b)(6)

~ontact Date: 6/8/2006

Clinical Provider:

pme Spent: 0 5

Type of Contact: In Person

'~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.

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(b)(6)

Date of Signature: 8/28/2007

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Case Number 11257 Client Name:

(8)(6}
-----

Contact Date: 4/14/2006

Clinical Provider:

Time Spent: 0

Type of Contact:

(b}(6}

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

:

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Signature of Provider:

(b}(6)

Date of Signature: 4i14i2006

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( ase Number i 1947 Client Name:

(b)(6)

1 ontact Date: 3/15/2007

Clinical Provider:

" ime Spent: 3

Type of Contact: Phone

4

(b)(6)

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
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(b)(6)

Date of Signature: 3i15/2007

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:ase Number 11947 Client Name:

(b)(6)

--

Contact Date: 3/14/2007

Clinical Provider:

[Time Spent: 3

Type of Contact:

---

(b)(6)

~ollateral Contact:

-

:summary of Contact:
14 March 2007
0 rev1ew this date Closed as resolved.
!

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(b)(6)

--~Date of Signature: 3!14!2007

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(b)(6)
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ase Number 11947 Client Name:

(b)(6)
_,_~·--··-

:ontact Date: 3/13/2007

Clinical Provider:
Type of Contact: Phone

ime Spent: 0.5
ollateral Contact:

--------

-

t>ummary of Contact:
13 March 2007
· ~ to SM @ work.
purt pv-<.
;'f,i

--

(b)(6)

to determme court status Still continumg on sessioin 39. Court last month. He Will drop off his

!-;;_.-

•pig nature of Provider:

(b)(6)

Date of Signature: 3/13/2007

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( ase Number 11947 Client Name:
! ontact Date: 12/20/2006

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Clinical Provider:

ime Spent: 1
1 ollateral

(b)(6)
--

-

(b)(6)

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Type of Contact:

Contact

t-~·

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ummary of Contact:
PO December 2006
9) day rev1ow til is date
pxt "' 03-14-07.

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(b)(6)

Date of Signature: 12/21/2006

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( ase Number 11947 Client Name:

(b)(6)

Clinical Provider:

vontact Date: 10/4/2006

(b)(6)

Type of Contact: Other

ime Spent: 3

--

----

:oflateral Contact:
• 3ummary of Contact:
· 29 September 2006
He said that he has attened 24 sessions and his next court date on 24 October.He will
' C to SM at horne number, (b)(6)
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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(b)(6)

Date of Signature: 10/4/2006
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FAP Clinical Contact Note
. Case Number 11947 Client Name:

(b)(6)
(b)(6)

Contact Date: 8/24/2006

Clinical Provider:

Time Spent: 1

Type of Contact: In Person

Collateral Contact:

---

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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(b)(6)

Date of Signature: 8/24/2006

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(b)(6)

Case Number 11947 Client Name:

-~-

Contact Date: 7/12/2006

Clinical Provider:

(b)(6)

--·-

Type of Contact:

Time Spent: 3

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
(b)(6)
C to SM at his new work number
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-

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1s 4 October.

-·-----· --

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Date of Signature: 7/12/2006
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FAP Clinical Contact Note

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Case Number 13149 Client Name

(b)(6)
---

Contact Date: 712512006

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

(b)(6)

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.

--

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Signature of Provider

(b)(6)

Date of Signature: 7'26/2006

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!Administrative Note
Case Number 14509 Client Name:
Contact Date:
p/23/2006
Provider's Name:
(b)(6)

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Appointment Administration:
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
16 weeks.

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(b)(6)

¢ase Number 60118 Client Name:
~ontact Date: 6/11/2009

-[Type of Contact: In Person
. ime Spent: 1.5.
~umber of Individuals Seen: 1
!Type of Session: Individual
r-ype of Counseling Group: Offender Group
pession Notes:
~ake-up session for missed DV Group. Content of session was on empathy for spouse and
raking spouse feel "safe" within the relationship. ADM described personal communication
tyle and identified additional ways of more effective communication between himself and his
~ouse with specific emphisis on the actual message delivered. Another identified area not
reviously tried was to determine that in any discussion, both parties "come away with
omething" or with some small gain. Active listening was role-played and also defined was
. ally listening to another v. just waiting for your turn to speak.
tOM continues well engaged and motivated to be successful.
. OM feels he is deriving benefit from treatment
!OM will return on 12 June to make up second missed session.
Jflan Status

r

Continue Treatment Plan

~iagnostic Impression r Uncl1anged

r

Altered Treatment Plan

r F;eviseti

if~ecommended Referrals:

11-House FFSC:

/External Military:

!External
Civilian:

SIGNATURES

)ignature of Provider:

(b)(6)

IDate of Signature: 6/11/2009

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l~ontact Date: 6/10/2009
Itime Spent: 0
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Iype of Counseling Group:
ession Notes:
troup Note/Participation Form
tate: 1 0 June 2009 Client's Name:

jType of Contact:
jType of Session:

(b)( 6 l

Case manager:

troup Name:_ Cypress _ _ _ _ _ _ Group Leader(s): _
less ion# 4
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(~::;none; 2::;rarely; 3=sometimes; 4=often; 5=very often)

12 3 4 5 N/A

4cceptance Of Responsibility 4
~ersonal Disclosures 4
IEfmpathy for child and/or others x
~~;nowledge & Understanding of
Effective Parenting Strategies x
~ otivation for Change 4
I sight & Self Awareness into
IE ehavior 4
~espectful attitude 4
9verall Participation 4
.4:-FECT THERAPEUTIC CONCERNS
Lipbeat Incident of Re-abuse
guarded Suicidality
fjesentful Increased Risk of Re-abuse
qElm x Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective x Increased Stress
Irlappropriate Other_ _ _ _ _ _ __
Ffat None
Apgry
Si:id

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!+dditional Comments or Closing Summary:
~)~)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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$iagnostic Impression r UnclBnged r RevJ::;ed
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External Military:
l.n~House FFSC:

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JsiGNA TURES
Signature of Provider:
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jTri~Care:

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Case Number 60118 Client Name:
1

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f;ontact Date: 5/20/2009
time Spent: 0
"'umber of Individuals Seen: 0
rype of Counseling Group: Offender Group

/Type of Contact: In Person
jType of Session: Group

Session Notes:
proup Note/Participation Form

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{b)(6)

Case manager:

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~ession # 3
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1 =none; 2=rarely; 3=sometimes; 4=often; 5=very often)

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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
aim x Hostile, Aggressive Behavior
rustrated Increased Depression
~eflective x Increased Stress
Inappropriate Other_ _ _ _ _ _ _ __
flat None
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+dditional Comments or Closing Summary:
!fxcellent participation and disclosures. Listened effectively and offered insightful feedback to
d>thers.
Jl>lan Status

r

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Q>iagnostic Impression r Unchanged

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Altered ·T·reatrr1cnt

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lp-House FFSC:

jExternal Military:

jExternal Civilian:

lS!GNATURES

~ignature of Provider:

(b)(6)

I Date of Signature:

5/20/2009

jTri-Care:

1

abL

L-\) \.JJ

~

~
~

Clinical
Contact Note
r

(b)(6)

Case Number 60118 Client Name:
~ontact Date: 5/13/2009
Time Spent: 2
l
~umber of Individuals Seen: 1
type of Counseling Group: Offender Group
!
Session Notes:
~roup Note/Participation Form

I

pate: 13 May Client's Name:

(b)(6)

!Type of Contact: In Person

IType of Session:

Case manager:

(b)( 6l

I

~roup

Name: _Cypress

Group Leader(s): _

!
1

Session# 3

!
!

q:;ontent of Group:

I
I
=none; 2=rarely; 3=sometimes; 4=often; 5=very often)

r

2 3 4 5 N/A

cceptance Of Responsibility 3
ersonal
Disclosures 4
1
~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
!

I

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
---------------~

.tf1gry
~d

1\Pxious
obnfldent
R,bgretful
Qther
!
----~

(b)(6)

Group

._J_J

J

age ""' ut

lfdditional Comments or Closing Summary:
(b)(6)

participated very well today and was active in the discussion. He offered little feedback
fo others but listened attentively and was very forthcoming about his recent activities and his
felationship with (bl( 6 l and his son. (bl( 6 l will do well in the group and demonstrates
rnsiderable insight into relationship choices.
· ate:

~Revised

7/2006 t 61~
Plan Status r Continue 1 reatmeni

f.:.> Jan

r 1\ltored l reatrnent Plan

Diagnostic Impression r Unchanged r Rev1sed
~ecommended Referrals:
111-House FFSC:
'External Military:

I

!External
Civilian:

!SIGNATURES
~ignature of Provider:

!
!

I!
~

ii
I!
I

I
I.

II
1

!
l
I

I
I

I
t

!
~

l

I

I
I
t

~

t

(b)(6)

j Date of Signature: 5/13/2009

ITri-Care:

.J.,

~
~
i

~linical Contact Note

(b)(6)

Case Number 60118 Client Name:
f;ontact Date: 5/6/2009
fime Spent: 2
tJumber of Individuals Seen: 1
fype of Counseling Group: Offender Group

------------------,
/Type of Contact: In Person
/Type of Session: Group

~ession Notes:
~roup Note/Participation Form
!

(b)( 6l

pate: 6 May Client's Name:

6
(b)( )

Case Manager:

~

froup Name: _Cypress

Group Leader(s):.

i

$ession # 1
fontent of Group: Relationships and Sex

I
i
I

.

=none; 2=rarely; 3=sometlmes; 4=often; 5=very often)
2 3 4 5 N/A
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

1
!!
!

JljFFECT THERAPEUTIC CONCERNS
4pbeat Incident of Re-abuse
Quarded Suicidality
~esentfullncreased Risk of Re-abuse
qalm x Hostile, Aggressive Behavior
F}"ustrated Increased Depression
~flective x Increased Stress
Inappropriate Other_ _ _ _ _ _ __
Flat
None
I
Atlgry
Sl:td

A~xious

Cf:>nfident
R~gretful
O~her_ _ _ __
~

A~ditional
'

Comments or Closing Summary:

(bl( 6 l

ruge

.:."1

u.1 .J.l

I
(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:
JRevised 712006 (

e;}(~.p)

plan Status r. Contmue -i rec::.ltiTient Plan
giagnostic Impression r UriCIIi:.mgerj
~ecommended

!External Military:

fAP
!SIGNATURES
)Signature of Provider:

(b)(6)
-··--·-·

I'

I

'
I.

t

II
I!
I

I
!!
I

!

~

~ r\8VIS8::l

Referrals:

In-House FFSC:

!~

r /O..Itered Treatrnent P1a11

!External
Civilian:

IDate of Signature: 5/6/2009

JTri-Care:

PJgc 6 of 2!

I
~

J

li

i

I FAP Clinical Contact Note

ICase Number 54017 Client Name:
~tact Date: 5/27/2008
!_,Time Spent: 1

(b)(6)
-~

Clinical Provider:

(b)(6)

Type of Contact: In Person

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

~-

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12/27/20 ]()

Page 7 of 21

FAP Clinical Contact Note

(b)(6)

Case Number 54017 Client Name:
......
Contact Date: 5/2312008

Clinical Provider:

Time Spent: 0.25

Type of Contact: Email

(b)(6)

. 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
(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.
l-AC, San Diego Naval Base, buildrng 261. Since

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.
ure of Provider:

6
(b)( )

Date of Signature: 5/23/2008

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Page 8 of 21

Clinical Contact Note
(b}(6)

t Date: 5i23i2008

Clinical Provider:

r---------

1Time Spent: 0.25

(b)(6}

Type of Contact: Phone

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
tROM: F/l.MIL Y ADVOCACY {;J='NTER, SAN DIEGO NAVAL BASE
RE . .
(b)(6)
DUI HEARING ol 6 JUNE 2008

t

Iil

b.A.·I t: · 2:J MAY 2008

!his 1s to confirm that

.,~iolence. 20

'' "' ?nnQ
$uccessfully
(b)(S)

(b}(S)
1s scheduled to begin a s1xteen sess1on men's offender group in domestic
(b )(S)
1as expressed an eagerness to beglfl th1s treatment series and to complete 11

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

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Administrative Note
Case Number 54017 Client Name:
Contact Date:
5/5/2008

(b)(6)

Appointment Administration: Not applicable

~--~~~----~--~--~~--------------------------------------------------------~
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
must first attend an Educational Session which is
at the FAC. To begin this program,
scheduled for 20 Jun 08 from 0830-1200 11rs. Thank you very much.

v/r

(b)(6)

case Manager
Naval Base San Diego
Comm :619·556-6438
DSN: 526-6438
Fax: 619-556·9678
rAI-'

"For Offic1al Use Only- Privacy Sensitive" Any misuses or unauthorized disclosure may result
civil and criminal penalties .

.mii/componcnts/fonns/PrintAI!Fornls.aspx

1n

both

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FAP Clinical Contact Note
Case Number 54017 Client Name:
Contact Date: 4/16/2008

(b)(6)
(b)(6)

Clinical Provider:
~--

Time Spent: 0.25

Type of Contact: Phone

--

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.

Signature of Provider:

(b)(6)

Date of Signature: 4/16/2008

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P<:tge 18 of 21

J ' ' •.-·-·------~----------------------·-·>X<·'''''-~"'""'~-=•·'•><>,
j FAP Clinical Contact Note
Case Number 54017 Client Name:

(b)(6)

(b)(6)

Contact Date: 3/5/2008

Clinical Provider:

Time Spent: 0.25

Type of Contact: In Person

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
· (1) ( (Q)
as this is an approved provider.

b)(r,;,)

SIGNATURES
Signature of Provider:

(b)(6)

Date of Signature: 315/2006

'

1
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FAP Clinical Contact Note
Case Number 54017 Client Name:

6
(b)( )

Contact Date: 1i18/2008

Clinical Provider:

Time Spent: 0.25

Type of Contact: Phone

(b)(6)

Collateral Contact: GOVERNMENT AGENCYiORGANIZATION
Summary of Contact:
Spoke with CFAR
Jan 08.

(b)(6)

who stated that she arranged for SM to attend the Anger Mgmt class at FFSC on 29

r-·;1GNt\TU !ES
Signature of Provider:

(b)(6)

Date of Signature: 1/18/2008

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lCUnical Contact Note

lease Number 55987 Client Name:

(b)( 6 l

!contact Date: 7/22/2008

!Type of Contact: In Person

1Ti'!le Spent: 1.5
~Number of Individuals Seen: 1
1::
!\Type of Counseling Group: Offender Group

fType of Session: Group

~$ession Notes:
'Group Note/Participation Form

1-)ate: 7/22/08 Clien~s Name: (b)(6)
~ase Manager: (b)( )
(b)(6)
Group Name: Hawk Group Leader(s):
Session # (for this client) 16
!Content of Session: Time out
~ssign a number value to each category: 1=none; 2=rarely; 3=sometimes; 4=oflen; or N/A
jAcceptance of Responsibility· 4
Personal Disclosures: 4
f:rnpathy for others: 4
Knowledge & Understanding of
fltective Parenting Strategies: 4
~olivation tor Change 4
ltlespectful attitude: 4
!j)verall Participation: 4
[fut an "X" for those that apply:
~'.FFECT:

IVpbeat Flat
<j>uarded Angry
l~esentful Sad
(~aim x ;\mdous
Ffrustrated Confident X
f~ellective X Regrc:tful
q)ther (state type):
1!HERAPEUTIC CONCERNS:
hkident ol Re-abuse
~~uicrdality
hkreasod Risk of Re-abuse
fiostile, Aggressive Behavior
lricreased Dcpressron
lricreased Stress
qther:
Nonex
cfJMMENTS or SUMMARY: SM reported that over the weekend his g~rlfriend was hit by a drunken driver. She was not hurt,
brill the car sustained some damage. He related how upset he was and that he went to find her and the driver, but resisted
H\'e urge to hit hirn. He also completed the switch exercise and identified at what point he could have avoided the incident. At
th~ beginnrng when she asked him to go to the bowlmg alley with h1m he should have been truthful with her as to the reason,
in~tead of using a lame excuse. Maybe that would havA nnt ''nc:"'t her so much. He has completed sess1on 16 and has made
g1~at progress since the 1st session.
(b)(6)

~~

P~n Status

.


D~gnostic Impression

.

'

.

.

~-·

:

.

R+commended Referrals:
h1~House FFSC:

-··

of Provider:

..

'.

:
•..

IExternal Military:

?.~lG

S~nat

..

:

·.

(b)(6)

!External Civilian:

I

!Tri·Care:

-

Date of Signature: 712412008

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\Administrative Note
jCase Number 55987 Client Name:

~ntact Date:

7/15/2008

1 Provider's Name;
(b)(6)

(b)(6)

(b)(6)

Appointment Administration: Rescheduled

Administrative Notes:
Group Note/Participation Form
Date: 7/15/08 CI/~R~) Name: (b)(6)
Case Manager:
Group Name: Hawk Group Leader(s)·.
(b)(6)
Sess1on If (for this client) excused
Content of Sess1on:
Assign a number value to each category: i =none; 2=rarely; 3=some!Jmes: 4=often; or
N/A
Acceptance of Responsibility:
Personal DiSclosures:
Empathy for others:
Knowledge & Understanding of
Effective Parenting Strateg1es:
Motivation for Change:
Respectful attitude:
Overall PartJcipahon:
Put an "X" for those that apply:
AFFECT:
Upbeat Flat
Guarded Angry
Resentful Sad
Calm Anxious
Frustrated Confident
Reflective Regretful
Other (state type):
THERAPEUTIC CONCERNS:
Incident of Re-abuse
Suic1dality
Increased Risk of Re-abuse
Hostile, Aggressive Behavior
Increased Depression
Increased Stress
Other:
None
COMMENTS or SUMMARY: Clhent called and cancelled - having to work.
(b)(6)

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Clinical Contact Note
(b)(6)

of Individuals Seen: 1
of Counseling Group: Offender Group

Session Notes:
proup Note/Participation Form

bate: 7!08!08 Client's Name: (b)(6)
base Manager: (b)(B)
~;roup Name: Hawk Group Leader(s).
(b)(B)
$ession # (for this client) 15
tontent of Session: Listening to Ch1ldren
~ssign a number value to each category 1=none: 2=rarely; 3=sornetlmes: 4=often; or WA
'*'cceptanctJ of Responsibility: 4
f?ersonal Disclosures: 4
fX:rnpathy for others: 3
l{nowledge & Understanding of
Q;ffective Parenting Strategies: 4
f}lotivation for Change: 3
liespectful attitude: 4
Cllverall Participation 3
Hut an "X" for those !!1at apply
AFFECT:
L!pbeat Flat
C~uarded Angry
Fiesentful Sad
C1alm x Anxious
F~·ustrated Confident
fiefiectrve Regretful
either (state type):
THERAPEUTIC CONCERNS:
lrlcident of F1e-abuse
S~rcidality

lr/ocreased Risk of Re-abuse
Hbstile, Aggressive Betlavror
lnrreased Depression
lnbeased Stress
Ol.her:

Nl:mEJ x
ctJMMENTS or SUMMARY: : SM reported that this past weekend he and grrifnend argued agatn. He has decided to end the
relationship. She has moved in with a friend for the trrne being. He reports that he rs willing to help her financially for rent so
thi:lt his son is well takon r.r1re of
(b)(6)

(b)(6)

Date of Signature: 718!2008

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inistrative Note
(b)(6)
Date: 7/1/2008
Name:

Appointment Administration: Cancelled
(b)( 6 )

Administrative Notes:
Group Note/Participation Form
Date: 7/1/08 Client's Name: (b)(6)
Case Manager: (b)(G)
Group Name: Hawk Group Leader(s):
(b)( 6 )
Sess1on # (for this client) excused
Content of Sess1on
Assign a number value to each category: 1=nono; 2=rarely; 3=sometJmes; 4=often, or

N/A
Acceptance of Respons1b11ity:
Personal Disclosures:
Empathy for others:
Knowledge & Understandmg of
Effecllve Parenting Strateg1es:
Molivalion for Change:
Respectful attitude:
Overall Participation
Put an "X" for those !hat apply:
AFFECT:
Upbeat Flat
Guarded Angry
Resentful Sad
Calm Anx1ous
Frustrated Confident
Reflective Regretful
Other (stale type):
THERAPEUTIC CONCERNS:
Incident of Re-abuse
Suicidality

Increased Risk of Re-abuse
Hos!lle, Aggressive Behavior
Increased Depress1on
Increased Stress
Other:
None
COMMENTS or SUMMARY:

(b)(6)

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:Clinical Contact Note
Case Number 55987 Client Name:

(b)( 6 l

Session Notes:
Group Note/Participation Form
lDate: 6/24/08 Client's Name: (b)( 6)
jCase Manager: (b)(6)
iGroup Name: Hawk Group Leader(s)
(b)(6)
Sess1on II (for this client) 14
Content of Sess1on: Sexual Abuse
Ass1gn a number value to each category: 1=none; 2=rarely, 3-=somctlmes. 4=often: or NIA
!Acceptance of Responsibility: 3
!Personal Disclosures: 3
~Empathy for others: 3
~Knowledge & Understanding of
!,Effective Parenting Strategies: n/a
lr.1otivation for Change: 3
',Respectful allitude: 4
Overall Part1c1pat,on: 3
Put an "X" for t11ose mat apply:

I

!

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
ftostdo, Aggrossivo Bohavior
Depression
Stress

l

X

COMMENTS or
(b)(6)

<::1 IMhAhOV: :

SM reported tllat he has llad a good week. He participated in discussion of weekly top1c.

External Military:

External Civilian:

(b)(6)

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Contact Note
(b)(6)

Type of Session: Group

6/17!08 Client's Name: (b)( 6)
Manager: (b)( 6 )
Name: Hawk Group Leader(s):
(b)(6)
"'"'~'"'"' # (for !t1is client) 13
of Session: Handling Critic1sm
a number value to each category: 1=none; 2"'rarely; 3:o:sometimes; 4=often; or N/A
of Responsibility 3
Drsclosures 3
for others: 3
& Understanding of
Parent1ng Strategies: n/a
for Change: 3
attitude: 4

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)
'
'

External Military:
(b)(6)

External Civilian:

Date of Signature: 6/18i2008

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Page 10 of 30

Clinical Contact Note
Case Number 55987 Client Name:

(b)(6)

He has completed 10/10 sess1ons of Group KuhlanL Thoro flavo not boon

Signature

or Provider:

(b)(6)

Date of Signature: 6/13/2008

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Contact Note
(b)(6)

6/13/2008 Client's Name: (b)(6)
Manager: (b)( 6 )
Name: Hawk Group Leador(s)
(b)(6)
# (for this client) 12
of Sess1on: Feelings
a number value to each category. 1=none; 2=rarely; 3=sometimes: 4=often; or N/A
of Responsibility: 3
Disclosures: 3
for others: 3
novvle<JOe & Understanding of
Strategies: n/a
lor Changu 3
attitude: 4

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)

External Military:

Civilian:

Signature: 6/13/2008

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Page 12 of]()

Contact Note
(b)(6)

(b)(6)
Name
(b)( 6 )
Case Manaaer·
(b)(6)
Name: K.nUiam I Group Leader(s):
Attended: 10 .t\bsent Halfway point: Final Sessron: X
of Group: One new group member attended group today. Group members checked in with facilitators
mrnrr1nn incidents and descnpt1ons of their styles of parenting and what they need to work on. Topic of group was
and handouts were discussed and processed by all group memt)ers. Group member's shared individual
discipline tecilmques that work witll paren!ing skills. Group also watched "SOS" vrdeo on parenting.
a number value to eacil category 1=none: 2=rarely; 3=sometrmes: 4:=often; or N/A Acceptance of
Disclosures:3
!Smpathy for others: 3
'u"'""'''""' & Understanding of
Strategres: NA
for Change: 3
attitude: 3
Partrcipatiorl' 3
Put an ·x·· for those that apply: AFFECT:

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

External Military:

(b)(6)

Civilian:

Date of Signature: 6/13/2008

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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.

External Military:

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Civilian:

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(b)(6)

5/27/2008 Client's t..Jame: (b)(6)
Manager: (b)( 6 )
6
Name: Hawk Group Leader(s)
(b)( )
# (for this client) 11
of Sessron. Accountabllrty
a number value to each category: 1=none; 2=rarely; 3=sometrmes; 4=often; or N/A
of Responsrbrllty 3
Disclosures: 3
lor others. 3
'""'"'"'inn & Understandrng of
Strategres n/a
n.;r,ml;;>jt('Hl for Ctlange: 3
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)

Military:

smis.cruc .navy .milicomponents/forms/Pri ntAIIFonns.aspx

External Civilian:

12/27/20 l 0

Page I 5 of ;\()

Note
Case Number 55987 Client Name

(b)(G)

Appointment Administration: Not applicable
(b)(6)
(b)(6)

u:.Tir'HI"/" Notes:
Group NoteiParticipation Form

(b)(6)
Date: 5/21/2008 Client's Name:
Case Manager: (b)(G)
Group Name: Hawk Group Leader(s):
(b)(6)
Sess1on li (for this client) Excused
Content of Sess1on
Assign a number value to each category: 1=none; 2=rarely; 3=sometimes: 4=oltcn, or
N/A
Acceptance of Respons1bilit}":
Personal Disclosures
Empathy for others
Knowledge & Understandmg of
Effective Parent111g Strategies:
Motivation for Change:
Respectful att1tude.
Overall PartiCipation:
Put an ''X" for those that apply.
AFFECT:
Upbeat Flat
Guarded Angry
Resentful Sad
Calm Anxious
Frustrated Confident
Reflect1ve Regretful
Other (state type):
THERAPEUTIC CONCERNS:
Incident of Re-abuse
Suicidality
Increased R1sk of Re-abuse
Hostile, Aggressive Behavior
Increased Depressron
Increased Stress
Other·
None
COMMENTS or SUMMARY:
(b)(6)

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I

1, ;dministrati~~
1

.I

~:;:~~--~~ ··~-~···-·· ..

Case Number 55987 Client Name:
Contact Date: 5/13/2008

I Provider's Name:
(b)(6)

(b)( 6)

(8 H6 l
------~--------------------------,

Appointment Administration: Cancelled

Administrative Notes:
Group Note/Participation Form
Date: 5/13/2008 Client's Name: (b)(6)
Case Manager: (b)( 6)
Group Name: Hawk Group Leader(s):
(b)(6)
Session # (for this client) excused
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 for Change:
Respectful attitude:
Overall Participation:
Put an "X" for those that apply:
AFFECT:
Upbeat Flat
Guarded Angry
Resentful Sad
Calm Anxious
Frustrated Confident
Reflective Regretful
Other (state type):
THERAPEUTIC CONCERNS:
Incident of Re-abuse
Suicidality
Increased Risk of Re-abuse
Hostile, Aggressive Behavior
Increased Depression
Increased Stress
Other:
None
COMMENTS or SUMMARY:

(b)(6)

\

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Clinical Contact Note
Case Number 55987 Client Name:

l

(b}(6)

Contact Date: 4/30/2008
jType of Contact: In Person

Time Spent: i .5
Number of Individuals Seen: 1

!Type of Session: Group

Type of Counseling Group: Parenting

Session Notes:
Group Note/Participation Form
Date: 4/23/08
(b)(6)
(b)(6)
Case Manaaer:
Client's Name:
(b)(6)
Group Name: Khulani I Group Leader(s):
Sessions Attended: 5 Absent: Halfway point: Final Session:
Content of Group: Members shared updates on referring incidents over the week. Video clips on Antoine Fist1er were shown
to group members for 30 minutes. Group facilitators gave handouts on FOO. Facilitators assisted two group members with
processing their FOO history and handout questions
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.
Jan Status

Contir:ur Troatrn<~nt F'!dn

!agnostic Impression
ecommended Referrals:
I -House FFSC:

UnchannecJ

/'d\~_;u.:{/

T rOi!ifl!Clit

F)irlll

Ht:~\!~~-.;c;r.!

TExternal Military:

!External Civilian:

!Tri-Care:

SIGNATURES
' ignature of Provider:

(b}(6)

JDate of Signature: 5/22/2008

I

I!
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I

Clinical Contact Note

i Case Number 55987 Client Name:

6
(b){ )

I Contact Date: 4/29/2008

!Type of Contact: In Person

Time Spent: 1.5
Number of Individuals Seen: 1
Type of Counseling Group: Offender Group

jType of Session: Group

Session Notes:
Group Note/Participation Form
(b)(6)

Date: 4/29/2008 Ytl\fl)fs Name:
Case Manager: b
(b)(6)
Group Name: Hawk Group Leader(s):
Session# 10
Content .of Session: Anger ladder
Assign a number value to each category: 1=none; 2=rarely; 3=Sometimes; 4=often; or N/A
Acceptance of Responsibility: 4
Personal Disclosures: 4
Empathy for others: 3
Knowledge & Understanding of
Effective Parenting Strategies: N/A
'Motivation tor Change: 3
· f1espectful attitude: 4
pverall Participation: 3
Put an "X" for those that apply:
C..FFECT:
,Jpbeat Flat
puarded Angry
~esentfuiSad
.;aim X Anxious
rustrated Confident
· 1\eflective X Regretful
)ther (state type):
HERAPEUTIC CONCERNS:
lw1dent of Re-abuse
IE uicidality
I creased Risk of Re-abuse
It- ostlle, Aggressive Behavior
~creased Depression
creased Stress
ther:

rI

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

Hf_~v,r;f~.:-.i
Uncharl(;GC
Dl ~gnostic Impression
RE commended Referrals:
hr ~ouse FFSC:
External Mllltary:

I

IExternal Civilian:

jTri-Care:

S GNATURES
Si~nature

I

of Provider:

(b){6)

IDate of Signature: 4/30/2008

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,,v

Clinical Contact Note

I Case Number 55987 Client Name:
Contact Date: 4/23/2008
I' Time
Spent: 1 .5

(b)(6)

jTl::pe of Contact: In Person

Ii Number of Individuals Seen: 1
j

of Counseling Group: Parenting
I1 Type
Session Notes;

'!Type of Session: Group

1 Group Note/Participation Form
l Date: 4/23/08
(b)(6)
Client's Name:
~') Case Manaaer
(b)(6)
Group Name: Khulani I Group Leader(s):
Sessions Attended: 5 Absent: Halfway pomt: t-1na1 ~ess1on:
Content of Group: Members shared updates on referring incidents over the week. Video clips on Antoine Fisher were shown
to group members for 30 minutes. Group facilitators gave handouts on FOO. Facilitators assisted two group members with
process1ng their FOO history and handout questions
·

Ub) (

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

~iagnostic

Contn,LH"·

·r rr;uin1en:

Impression

PL·J: i

Unchtlfl~IL:CJ

!\!i_(;; ("(i Tlc~ntn1cnt F1 ldn
Hc:vl'~od

ecommended Referrals:
I -House FFSC:

.!External Military:

lExternal Civilian:

jTri-Care:

piG NATURES
~ignature of Provider:

Il

(b)(6)

IDate of Signature: 5/22/2008

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I
Ii
I Clinical Contact Note

j Case Number 55987 Client Name·

(b)(6)

Contact Date: 4/22/2008

I

jType of Contact: In Person

I Time Spent: 1.5
\ Number of Individuals Seen: 1

I

I

!Type of Session: Group

Type of Counseling Group: Offender Group
Session Notes:
Group Note/Participation Form

I
l

Date: 4/2212008 Client's Name: (b)(6)
Case Manager: (b)(6)
(b)(6)
Group Name: HawK Group Leader(s):
Session# 9
Content of Session: Anger ladder
Assign a number value to each category: 1=none; 2=rarely; 3=sometimes; 4=often; or N/A
Acceptance of Responsibility: 4
Personal Disclosures: 4
Empathy for others: 3
Knowledge & Understanding of
Effective Parenting Strategies: N/A
Motivation for Change: 3
Respectful attitude: 4
Overall Participation: 3
Put an "X" for those that apply:
AFFECT:
Upbeat Flat
Guarded Angry
Resentful Sad
Calm X Anxious
Frustrated Confident
Reflective X Regretful
Other (state type):
THERAPEUTIC CONCERNS:
Incident of Re-abuse
isuicidality
ncreased Risk of Re-abuse
Hostile, Aggressive Behavior
ncreased Depression
ncreased Stress
pther:

r

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.

I

I

(b)(6)

~~lan Status

(:unt!i:Uc T:c:;,:;tn:c::t

Qliagnostic Impression

l_

1-~[d;':

J·-)cjJ~lnq(•:_i

lftecommended Referrals:
l
1(1-House FFSC:

."\itt;l ~:cl f 1 cdtrnc;nl Pian
Hr:v~.-.c.-_i

IExternal Military:

!External Civilian:

!Tri-Care:

ltGNATURES
$ignature
of Provider:
;

(b)(6)

j Date of Signature: 4.'23/2008

I
1l
l

l
l

l

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j

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\

I Clinical Contact Note
I C ase N urn b er 55987 Cl'1ent Na me:

(b)(6)

Contact Date: 4/16/2008

jry~e of Contact: In Person

Time Spent: 1.5
Number of Individuals Seen: 1
Type of Counseling Group: Parenting

!Type of Session: Group

Session Notes:
Group Note/Participation Form
Date: 4/16/08
(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.

{p ){f:. \

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-;

Dl4tgnostic Impression
R*ommended Referrals:
In· -louse FFSC:

:..._lf:G!\L;i)\;C;C

l'-·d\>~:!'.~C~

Tu.-t:i:nJ(:rr

r:·tcl!·

r:;(!\.-f~.c.7cJ

I External Military:

!External Civilian:

ITri·Care:

S GNATURES
Si nature o1 Provider:

(b)(6)

IDate of Signature: 5/22/2008

l

I

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I!

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Page 23 of 30

I
i!

1 Ad . .
. Note
1
mmastrattve
Case Number 55987 Client Name:

I

Contact Date: 4115/2008

I
I

Provider's Name:

(b)(6)

Appointment Administration: No show

(b)(6)

Administrative Notes:
Group Note/Partictpa!ion Form

(b)(6)

Date: 4/15/2008 \.li~>'1t'S Name: (b)(6)
Case Manager: (b)( 6 )
(b)(6)
Group Name: Hawk Group Leader(s):
Session :# (for this client) absent
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
Resentful Sad
Calm Anxious
Frustrated Confident
Reflective Regretful
Other (state type):
THERAPEUTIC CONCERNS:
Incident of Re-abuse
Suicidality
Increased Risk of Re-abuse
Hostile, Aggressive Behavior
Increased Depression
Increased Stress
Other:
None
COMMENTS or SUMMARY:

'

I
l
l

l
I
I

l

Il

I
I
j

I'

I

(b)(6)

I

I
\

I

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Page 24 of 30

Clinical Contact Note
Case Number 55967 Client Name:

!

'!
i

(bl( 6 l

Contact Date: 419/2008

!Type of Contact: In Person
t Time Spent: 1 .5
I Number of Individuals Seen: 1
\
jType of Session: Group
Type of Counseling Group: Parenting
l Session Notes:
Group Note/Participation Form
Date: 4/09/08 ( ) ( )
(b)(6)
Client's Name: .b
(, . ~ Case Manager
1 Group
(b)(6)
Name: Khulani I Group Leader(s):
'
Sessions Attended: 3 Absent: Halfway p01m r1na1 oess1on:
Content of Group: All members shared introductions of refernng incident due to two new group members today. Group
facilitators gave handouts on Anger and Alternatives to lashing out. . 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.

I
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 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:

D agnostic Impression
A commended Referrals:
In House FFSC:

tJJ ~~:t1~1r)9F:d

/\\loi ud -1 1c~·lt!lH:::>nt

Pi~P·\

F,t:'/1::_;(-~Ci

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

--

Clinical Contact Note
Case Number 55987 Client Name:

(b)(6)

Contact Date: 4/2/2008
IT vee of Contact: In Person
Time Spent: 1.5
Number of Individuals Seen: 1
[Type of Session: Group
Type of Counseling Group: Parenting
Session Notes:
Group Note/Participation Form
Date: 4/02/08
(b)(6)
Case Manager:
Client's Name: b
1.:>
(b)(6)
Group Name: Khulani I Group Leader(s):
Sessions Attended: 2 Absent: Hallway po1nt: Fmal Session:
Content of Group: All members shared introductions of referring incident due to new group member today. Group facilitators
gave handouts on Domestic violence and how the Cycle of violence affects children. Watched video last 10 minutes on
· "Hidden Victims" and processed feelings after video. Group addressed their own experiences with the cycle of violence in
FOO, and their current relationships. Group also shared the healthy wheel of equality and identified which section they need
to work on.

Q) ( )

~'

-··~·

'

1

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

Dlbgnostic Impression
Rdcommended Referrals:
lntJouse FFSC:

Ut.!CI"!Uri;:£:-;·~

/\1\('l ~:·n ~~ ~t>Jttn·:;n: f- 1 !~-tl:
f."-\eVi'~.·.. {.·~

!External Military:

!External Civilian:

jTri-Care:

SjGNATURES

Sl,nature of Provider:

(b)(6)

IDate of Signature: 5!22/2008

I
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Page 27 of 30

Clinical Contact Note
Case Number 55987 Client Name:

(b)(6)

Contact Date: 3/26/2008
!Type of Contact: In Person

Time Spent: 1 .5
Number of Individuals Seen: 1

!Type of Session: Group

Type of Counselin9 Group: Parenting

Session Notes:
Group Note/Participation Form
Date: 3/26/08
(b)(6)
(b)(6)
Case Manaoer:
Client's Name:
(b)(6)
Group Name: Knulani 1Group Leader(s):
Sess10ns Attended: 1 Absent: Halfway p01m: t-rnal Session: X
Content of Group: All members shared introductions of referring incident due to new group member today. Group facilitators
gave handouts on Domestic violence and how D.V. affects children. Watched video "Hidden Victims" and processed feelings
after video. Group addressed their own experiences of D. V. in FOO, and discussed how this has affected their adulthood.
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

Di gnostic Impression

A! !commended Referrals:
In· House FFSC:

Pl::-1n

Uncl-~~-~~·~qe(_i

!.\.He;:-)(! Ttu:

!ll:Uii' r.::L-;!:

!- \P \:\ ~-~\.:(!

IExternal Military:

IExternal Civilian:

/Tri-Care:

S GNATURES
Si,nature oi Provider:

(b)(6)

IDate of Signature: 5/2212008

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Clinical Contact Note

(b)(6)

Case Number 58410 Client Name:
Contact Date: 3/10/2009
Time Spent: 1.5
Number of Individuals Seen: 1

!Type of Contact: In Person

Type of Counseling Group: Offender Group

!Type of Session: Group

Session Notes:
Group Note/Participation Form
Date: 25 Client's Name:

(b)(6)
(b)( 6 )

Group Name: Cypress Group Leader(s):
Session# 12
Content of Group:

I (1 =none; 2=rarely; 3=sometimes; 4=often; 5=very often)
1 2 3 4 5 N/A
Acceptance Of Responsibility x
Personal Disclosures x
Empathy for child and/or others x
Knowledge & Understanding of
Effective Parenting Strategies x
Motivation for Change x
Insight & Self Awareness into
Behaviorx
Respectful attitude x
Overall Participation x
AFFECT THERAPEUTIC CONCERNS

! Upbeat Incident of Re-abuse
Guarded Suicidality
Resentful Increased Risk of Re-abuse
Calm Hostile, Aggressive Behavior
l::rustrated Increased Depression
fietleclive Increased Stress
napproprlate Other_ _ _ _ _ _ __
Flat None
f\ngry
pad
P,nx10us
ponfident
f!egretful
~!her_ _ __
dditional Comments or Closing Summary:
(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!

Date: _25 Feb 2008. _ _ _ _ _ _ _ __
!1evised 7/2006

~I~)

Jan Status C" Contmur Treatmon! rian
iagnostlc Impression C UnchangecJ

C Al!i,lfecl Treatment Plan
C' FitWIScid

ecommended Referrals:

l

·House FFSC:

IExternal Civilian:

JExternal Military:

!Tri·Care:

ISIGNATURES
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Signature of Provid.,r

(b)(6)

Date of Signature: 3/1 0/2009

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Clinical Contact Note
(b)(6)

!Case Number 5841 0 Client Name:
Contact Date: 2/19/2009
!Time Spent: 1.5
Number of Individuals Seen: 1
rType of Counseling Group: Ofiender Group
, !session Notes:
J ~roup Note/Part1cipat1on Form

!Type of Contact: In Person
TType of Session: Group

(b)(6)

pate: 18 Feb 09 Client's Name:
proup Name: Cypress Group Leader(s):

(b)(6)

~ession # 11
pontent of Group:
1-=none; 2=rarely; 3=sometimes; 4=often; 5=very often)
2 3 45 N/A
looeplaooe Of Reepoosibmly'
ersonal Disclosures x
mpathy for child and/or others x
• nowledge & Understanding of
: ffective Parenting Strategies x
~ otivation for Change x
'ihsight & Self Awareness into
ehavior x
tiespectful attitude x
'bverall Participation x
FFECT THERAPEUTIC CONCERNS
pbeat Incident of Re·abuse
uarded Suicidality
esentfullncreased Risk ot Re-abuse
aim x Hostile, Aggressive Behavior
rustrated Increased Depression
eflective x Increased Stress
appropriate Other
. at None
ngry
~d
hxious
pnfident

I

~~~gretful

1~ her~

I

if.t:Jditional Comments or Closing Summary:
(b)(6) continues to participate actively. He accepts feedback from others but fails to grasp
ttP=l futility of his "rather be right than happy" attitude toward his marriage.

I
~
I

te: _ i8 Feb 2009

(~ evised 7/2006 i(b~)

1~1 an Status f' Contmue Trcntrnrmt Plan
~~~ agnostic Impression C Unchan~)ecl

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commended Referrals:
I~ House FFSC:

C /\ltmoci Tmatrncnl Plan
C HrwJsocl

IExternal Military:

IExternal Civilian:

jTri-Care:

$1GNATURES

~

nature of Provider:

(b)(6)

j Date of Signature: 2/19/2009

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Clinical Contact Note
(b)(6)

Case Number 58410 Client Name:
Contact Date: 2/12/2009
Time seent: 1.5
Number of Individuals Seen: 1

!Type of Contact: In Person

Type of Counseling Group: Offender Group

!Type of Session: Group

Session Notes:
roup Note/Participation Form
(b)(6)

Date: 14 Jan 2009 Client's Name

Case Manager:

(b)(6)

Group Name: Cypress Group Leader(s):
Session#
Content of Group: Perception is Reality

(i=none; 2=rarely; 3=sometimes: 4=aften; 5=very often)

1 2 3 4 5 N/A
Acceptance Of Responsibility x
Personal Disclosures x
Empathy for child and/or others x
Knowledge & Understanding of
Effective Parenting Strategies x
MotiVation for Change x
Insight & Self Awareness into
-Behavior x
Respectful attitude x
bverall Participation x
. fA.FFECT THERAPEUTIC CONCERNS

rbeat looideot

of

AHb"'e

uarded Suicidality
esentful Increased Risk of Re·abuse
aim x Hostile, Aggressive Behavior
rustrated Increased Depression

rflactNe' looceasad Stmss

nappropriate Other
lat None x
ngry
ad
nxious
sonfident
egretful
ther

I

!'dditional Comments or Closing Summary: (b)(6) was supportive and atten!lve. He discussed his issues appropriately
nd listened effectivejyto others but needed to be encouraged to participate in the discussion. Quiet.

C Alic~red

plan Status I Cont!rll.w Tmaunenl rJon

:pi agnostic Impression

\

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Pii.lli

Flevrse~J

\ ecommended Referrals:
~n-House FFSC:

jExternal Military:

jExternal Civilian:

jTri·Care:

SH3NI\TURES

I~ignature of Provider:
II1!

(b)(6)
-----

IDate of Signature: 2/12/2009

11

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Llinical Contact Note
(b)(6)

tase Number 58410 Client Name·
!Contact Date: 2/12/2009
[rime Spent: 1.5
!Number of Individuals Seen: 1
jrype of Counseling Group: Offender Group

!Type of Contact: In Person
lrype of Session: Group

Fession Notes:
roup Note/Partlcipa!Jon Form

rto:

7 Jan 2009 Client'' Name;

Case Manager:

(b)(B)

roup Name: Cypress Group Leader(s):

~)

(b)(6)

teSSIOn !17

l

ontent of Group:

=no no: 2=cately;3=oomettmes;4=often ;S=vety often)
2 3 4 5 N/A

cceptance Of Responsibility x
: ersonal Disclosures x
1
mpathy for child and/or others x
: nowledge & Understanding of
i Hective Anger Management Strategies x
. ~otivation for Change x
nsight & Self Awareness into
ehavior x
espectful attitude x
verall Participation x

!
I
1

FFECT THERAPEUTIC CONCERNS
pbeat Incident of Re-abuse
uarded Suicidality
. esenttul Increased Risk of Re-abuse
aim x Hostile, Aggressive Behavior
I~ ustrated Increased Depression
If, eflective Increased Stress
I appropnate Other_
at None
rgry
~d

rxious
pnfident
~gretful

her
I
I
Aiiliitinl')al Comments or Closing Summary:
noted that CW drank over the weekend and became agitated and offensive, as she usually does. SM was able to
1<f 01 conflict, and avoided alcohol consumption throughout the weekend .. The group offered supportive feedback.

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~ljan Status

r

I 1\!ie:ec Treatment r"ian

ContlrHW Treairmml Pian

djagnostic Impression

I UnciElnqed

R commended Referrals:
I~ House FFSC:

r

Rov!i·3or:1

IExternal Military:

!External Civilian:

!Tri·Care:

~ iGI'JATURES
I

~ipnature

of Provider:

(b)(6)

j Date of Signature: 2/12/2009

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(b)(6)

Case Number 58410 Client Name:
_,

Contact Date: 2/12/2009
)Type of Contact: In Person

Time Spent: 1.5
Number of Individuals Seen: 1
Type of Counselin§! Group: Offender Group

jType of Session: Group

Session Notes:
Group Note/Participation Form
(b)(6)

Date: 7 Jan 2009 Client's Name
Group Name: Cypress Group Leader(s):

Case Manager: (b)(G)

(b)(6)

Session# 7
Content of Group:

I.(1 =none; 2=rarely;3=sometimes;4=often;5=very often)
1 2 3 4 5 N/A
}Acceptance Of Responsibility x
Personal Disclosures x
Empathy for child and/or others x
·Knowledge & Understanding of
~ffective Anger Management Strategies x
~ot1vation for Change x
nsight & Self Awareness into
~ehavior x
~espectful attitude x
verall Participation x
tFFECT THERAPEUTIC CONCERNS
pbeat Incident of Re-abuse
, uarded Su1cidahty
'~esentful Increased Risk of Re-abuse
'P-alm x Hostile, Aggressive Behavior
I rustrated Increased Depression
effective Increased Stress
rappropnate Other_
fat None
ngry
ad
nxious
onfident
egretful
· ther

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
( evised 7/2006

~)(~p)

~an Status

(.:on\JntiC Ttoa!rnent P;un

r

agnostic Impression

r

•.JriCinn9ed

~ commended Referrals:
I~ House FFSC;

{

Altered 1reatmont Pl<cm

HDVISI:ri

IExternal Military:

!· jQf.J!\TUHES
~~nature of Provider:

c

(b)(6)

!External Civilian:

jTri·Care:

I

Date of Signature: 2/12/2009

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(b)(6)

Number 58410 Client Name:
I Case
Contact Date:
2/12/2009

I

\Type of Contact: In Person

Time Spent: 1.5
I
I Number of Individuals Seen: 1

I

!Type of Session: Group

Type of Counseling Group: Offender Group

Session Notes:
I Group
Note/Participation Form

II

Date: 4 Feb 2009 Client's Name:

I

l

(b)(6)

Case Manager: (b)(6)
(b)(6)

Group Name: Cypress Group Leader(s):

i Session

II 9 Content of Group:

I

I

(1 =none; 2=rarely; 3:sometimes; 4=often; 5=very often)

J

; 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
!Motivation for Change x
l nsight & Self Awareness into
Behavior x
Respectful attitude x
Overall Participation x

I

f'.FFECT THERAPEUTIC CONCERNS
~pbeat Incident of Re-abuse
~uarded Suic1dality
Resentful Increased Risk of Re-abuse
~aim x Hostile, Aggressive Behavior
rustrated Increased Depression
~eflective x Increased Stress
: rappropnate Other
' Ia! None x
ngry
ad
nXIOUS
onfident
egretful
ther
ilddittonal Comments or Closing Summary:

I'

uiet but attentive. Offered supportive feedback to others

~~ate:~ 4 Feb 2009·
i

(pevised 7/2006 (b)(6)
lj

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r

CJnlilldC

~agnostic Impression

~
. ~commended

Treatrnc-nt

P~Hrr

(' UriCi;<mqt;cJ

.

Referrals:

r

Al\"'ed ·i r<:-:atrnqni Plan

(:' i={ovJ~,ed

IExternal Military:

I( House FFSC:

IExternal Civilian;

!Tri-Care:

f ;IGNt\TUHES
~ gnature of Provider:

(b)(6)

j Date of Signature: 2/12/2009

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Clinical Contact Note
(b)(6)

Case Number 5841 0 Client Name:
Contact Date: 2/12/2009

\Type of Contact: In Person

Time Spent: 1 .5
Number of Individuals Seen: 1
Type of Counseling Group: Offender Group

\Type of Session: Group

Session Notes:
Group Note/Participation Form
(b)(6)

Date: 11 Feb 09 Client's Name:

(b)(6)

Group Name: Cypress Group Leader(s):
Session# 10
Content of Group:

1=none; 2=rarely; 3=sometimes; 4=often; 5=very often)

h 2 3 4 5 N/A

'~cceptance Of Responsibility x
Personal Disclosures x
mpathy for child and/or others x
><nowledge & Understanding of
ffective Parenting Strategies x
Motivation for Change x
nsight & Self Awareness into
~ehavior x
spectful attitude x
erall Partictpation x

~

FECT THERAP. EUTIC CONCERNS
beat Incident of Re-abuse
uarded Suicidallty
i~esentful Increased Risk of Re-abuse
yalm x Hostile, Aggressive Behavior
rustrated Increased Depression
eflecttve x Increased Stress
11appropnate Other__ .________
lat None
: ngry
ad
nxious
onfident
egretful

,

i,

ther~~--1

iJ,fddittonal Comments or Clostng Summary:

!!
(b)( 6 )

~

reported that his wife has stopped drinktng. Apparently she became argumentative as soon as she started drrnktng

buper Bowl Sunday. and she reflected the next day that her alcohol abuse was ru1ning thetr marnage. Thts has been a

ge problem 1n the marnage, and SM appeared relieved. Members offered supporttve feedback.

I

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~

11 Feb 2009. _ _ _ _ _ _ _ __

(~evtsed 7/2006 (b)&~)----------------------------!

~~an

Status (" Cl'nllilllc' ; ;, iJLYt(·/1' i '',,n

rHagnostlc Impression (" Unchw>(jC!ci

~tcommended Referrals:
l~fHouse FFSC:

(" fll1c·, cd

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F'ldlt

(" Fit.l'JH;ic:Ci

\External Military:

IExternal Civilian:

jTri-Care:

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Signature of Provider:

(b)(6)

\ Date of Signature: 2/12/2009

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Clinical Contact Note
(b)(6)

!Case Number 58410 Client Name:

Contact Date: 12/18/2008
Time Spent: 1.5
Number of Individuals Seen: 1

)Type of Contact: In Person

Tyee of Counseling Group: Offender Group

)Type of Session: Group

Session Notes:
Group Note/Partic1pat1on Form
(b)(6)

Date: 12/10/08 Client's Name

(b)(6)

Group Name: Cypress Group Leader(s):
Session # 5

1

'( 1=none; 2=rarely;3=sometimes:4=otten;5=very ott en)
I

Acceptance Of Responsibility 3
Personal Disclosures 4
~mpathy for child and/or others 2
~nowledge & Understanding of
~ffective Anger Management Strateg1es 2
~otivation for Change 2
nsight & Self Awareness into
3ehavior
9espectful attitude 3
Dverall Partictpation 2
1\FFECT THERAPEUTIC CONCERNS

!pboat Jooldeot ot Ae-abose

. uarded SUtcidality
esenttul Increased R1sk of Re-abuse
1
, aim X Hostile. Aggressive BehaviOr
~rust rated Increased Depression
eflective Increased Stress
\pappropr\ate Other

i''

ngry
Nooe
ad

~nxious

onfident
egretful

~her
dit1onal Comments or Closino S1Jmmary: SM provided supportive feedback to other group members.
(b)(6)

~)an Status r

C:or!itl·l,Jt:' T ri:JU~rTlSltJ( P;arl

~ agnostic Impression r
R~commended

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Referrals:

If -House FFSC:

!External Military:

JExternal Civilian:

JTri-Care:

f ;!(;Nt,.TURES
~fgnature of Provider:

(b)(6)

[Date of Signature: 12/18/2008

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FAP Clinical Contact Note
(b)(6)

Case Number 92280 Client Name:
·---

"---·-·

ContactDate: 8/16/2010

Clinical Provider:

Time Spent: 0

Type of Contact: Email

(b)(6)

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

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Work: 619-556-3802 ext. 41 01/41 03

SIGNATURES
Signature of Provider;

(b)(6)

j Date of Signature: 8/16/2010

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I Contact Note
Number 92280 Client Name:

(b)(6)

Contact In
of Session:
Notes:
Group Note/Participation Form
(b)(6)
1ent's Name:
(b)(6)
Manager: :
Group Name: FA! CON
(b)(6)
Group Leader(s)·
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.

1=none; 2=rarely;3=sometimes;4==often;5=very often; NA=Not Assessed)

Of Responsrbiiity 2 Motivation for Change 1
Personal Disclosures 2 Insight & Self Awareness into
Behavior 1
Empathy for child and/or others 2 Respectful attitude 3
Knowledge & Understanding of
Management Strategies 1 Overall Participation 2
FECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded Suicidality
Resentful Increased Risk of Re-abuse
Hostile. Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
lnappropnate Other: Client appears to show little if any concern for others X
X None

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:

(b)(6)

of Signature: 9/13/2010

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(b)(6)

of Session:

(b)(6)

Manager·
(b)(G)
Name· FALCON
(b)(6)
Leader(s):
# 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).

1=none, 2=rarely ,3=sometimes;4=often,5=very often; NA=Not Assessed)
Of Responsibility 2 Motivation for Change 1
2 insight & Self Awareness into
Behavior 1
Empathy for child and/or others unknown Respectful att1tude 2
Knowledge & Understanding of
Management Strategies 1 Overall Participation 2

ECT THERAPEUTIC CONCERNS

no motivatton x

Regretful
Other-apathetic x
/;,dditional Comments or Closing Summary:

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[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)

Tri-Care:

External Military:

(b)(6)

of Signature: 9/27 i201 0

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(b)(6)

Number 92280 Client Name:

I Provider:

9/23/20'10

(b)(6)

·~············~··-~---~~.~~-~~--~~--·---------~--~-----+---------------·

Type...... of Contact: Ema1l

f--------···.: ______________________________.L _ __c___

---·~

·~···

·-·----~~·~

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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(b)(6)

of Contact: In Person
of Session: G

(b)(G)
Name:
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.

\1 =none:
rarely;3=sometimes;4=often;5=very often; NA:::::Not P.,ssessed)
Acceptance Of Responsibility 1 Motivation for Change 1
lns1ght & Self Awareness into
Behavior 1
Empathy for child and/or others 1 Respectful attitude 3
Knowledge & Understanding of
Management Strategies 1 Overall Participation 2
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 None

x

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

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improved, i e , bnnging h1s book, homework. and not picking at his nails during group

(b)(6)

External Military:

External
Civilian:

-----,------------------------------------------------------

Date of Signature: ·10/12i2010

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linical Contact Note
92280 Client Name:

(b)(6)
(b)(6)

10/14/2010
Contact: GOVERNMENT AGENCY/ORGANIZATION
of Contact:
s on leave today and therefore excused from Fa leon.

(b)(6)

(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

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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.

(1 =none: 2=rarely,3=sometimes;4=often;5=very often, NA=Not ,A,ssessed)
Of Responsibility 3 Motivation for Change 3
Insight & Self ;\wareness into

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

Comments or Closing Summary:

hu

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participated moderately low level, was quiet and did not take a leadership role in the
group considering the longev1ty of his membership and separation status as of the next week.

(b)(6)

External Military:

re of Provider:

(b)(6)

External
Civilian:

Tri-Care:

ofSignature: 10/28/2010

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ntact Note
92280 Client Name:

(b)(6)

In Person

of Session:

Group Note/Particrpation Form
Date: 71'1/iO
Client's Name
(b)( 6 )
Manager:
(b)(G)
Group Name: Fl\LCON
(b)(6)
Group Leaderis):
Session# 19
Content of Group,
Introduced staff change, provided group members with their own CHOICES book to use and
take home, began chapter 11 and reviewed homework assignment Also focused on client's
honest motivation for group (i.e Mandatory, enjoys group, drslikes therapist .. etc).

(1 =none; 2=rarei)J;3=sometrmes;4=often;5=very often, NA=Not Assessed)
Acceptance Of Responsibility NA Motivation for Change NA
Personal Disclosures 1 Insight & Self Awareness rnto
Betwv1or Nf\
Empathy for ch1ld and/or others NA Respectful attitude 4
Knowledge & Understandrng of
Anger Managernent Strategies NA Overall Participation 1
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

Comments or Closing Summary:
offers a smirk when called upon to participate. He is not rnitiating participation and
anxious and disengaged overall in group.

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ontact Note
Number 92280 Client Name:

(b)(6)

Contact In Person

of Session:
Notes:
Group Note/Participation Form
loate: 7/15/2010
!Client's Name:
(b)(G)
~ ·1
(b)(6)
li
1v anager:
IGroup Name F,AJCON
!Group Leader(s):
(b)(G)
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
rev1sit next week as clients ident1fy their own style and how they irnagine it impacts their
1
/' partner or other significant current relationships
Homework assigned and clients will be held
accountable for completing Quiz on pages 109-111.
1

(1 =none; 2=rarely,3=sometimes;4=often;5=very often; NA=Not Assessed)
Acceptance Of Responsibility 2 Motivation for Change 1-2
Personal Disclosures 2 Insight & Self Awareness into
Behavior 1
Ernpathy for child and/or others 2 Respectful attitude 1
Knowledge & Understanding of
/t'\nger Management Strategies 2 Overall Participation 2

AFFECT THERAPEUTIC CONCERNS
Upbeat lncrdent of Re-abuse
Guarded X SUicidality
Resentful Increased Risk of Re-abuse
Calm Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
lnappropnate Other: disinterested, distracted X
Flat X None
Angry
/Sad
Anxious
Confident
F~egretful

Other rnattentive X
Additional Comments or Closing Summary: Client demonstrated some Improvement in
participation but only with constant promptrng from facilitators. He appears distracted and

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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
group facilitators are attempting to better assess v1a greater verbal and vvritten participation
1
1
client.

I

(b)(6)

External Military:

(b)(6)

External
ian:

re:

Date of Signature: 7/16/2010

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1 7 2D 11

Clinical Contact Note
(b)(6)

Case Number 92280 Client Name:
Contact Date: 11/9/2009
Time Spent: 0
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

jType of Contact: In Person
jType of Session: Group

Session Notes:
Group Note/Participation Form

Date: 11/5/09 Client's Name:
(b)( 6 )
Case Manager:
Group Name: FALCON Group Leader(s): (};;)(_
Session# 1

lPJ

(b)( 6 l

Content of Group: (1=none; 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 1 Insight & Self Awareness into
Behavior 1
Personal Disclosures 1 Respectful attitude 3
Empathy for child and/or others 1 Overall Participation 2
·
Knowledge & Understanding of Anger
Management Strategies 1 Insight & Self Awareness into
Behavior 1
Motivation for Change 1
AFFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded X Suicidality
Resentful Increased Risk of Re-abuse
Calm X Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective Increased Stress
. Inappropriate Other_ _ _ _ _ _ __
Flat X None
Angry
Sad
Anxious
Confident
Regretful
Other
Additional Comments or Closing Summary:
6
This was
(b)( l
first group meeting. After introductions he was given an opportunity to
share with the group why he was there. He chose not to discuss this. During the group
exercise of completing an "Anger Inventory" he reported that he does not remember anything
about how his parents expressed anger. He went on to disclose that he was raised by his
grandmother. (b)(6 ) appeared to be somewhat overwhelmed by the group disclosure and
the group process.

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Clinical Contact Note
(b)(6)

Case Number 92280 Client Name
Contact Date: 11/19/2009
Time Spent: 0
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

jType of Contact: In Person
jType of Session: Group

Session Notes:
Group Note/Participation Form
(bl( 6 l
Date: 11/19/09 Client's Name:'
Group Name: FALCON Group Leader(s):
Session# 2

Case Manager:

(b)(

6

l

(b) (t.o)

Content of Group: (1=none; 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 2 Insight & Self Awareness into
Behavior 1
·
Personal Disclosures 3 Respectful attitude 4
Empathy for child and/or others 2 Overall Participation 3
Knowledge & Understanding of Anger
Management Strategies 2 Insight & Self Awareness into
Behavior 1
Motivation for Change 1
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:
1
6
(bl( l
liscussed why he was in the group. He disclosed that he was at a party, drank too
much and broke the front window of a female shipmate's apartment. He believes that alcohol
was the reason he behaved so poorly. During the group exercise of completing an "Anger
Inventory" he participated in group discussion about anger as a "normal" human emotion, and
aggression as a behavioral reaction to feelings of anger.
(bJ( 6 l
appeared to be somewhat
more comfortable with group disclosure and the group process.

https://flsmis.cnic.navy .mil/components/forms/ClinicaiContactNoteReoort.asox?Anolicatio ...

1/7/2011

Clinical Contact Note
(b)(6)

Case Number 92280 Client Name·
Contact Date: 1/14/2010
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

jType of Contact: In Person
jType of Session: Group

Session Notes:
Group Note/Participation Form
(bl(6 l
Date: 1/14/10 Client's Name:
Group Name: FALCON Group Leader(s):
Session# 3

Case Manager: l(b)( 6 l:

lvA._cc)

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_
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)( l participated in introduction exercise with 2 new members. He was quiet throughout
group although he responded when orompted by facilitators to describe his assessment of his
own level of self-awareness.
(b)( 6 ) had some difficulty articulating what warning signs let
him know he is experiencing tension, and what emotional, physical and cognitive indicators

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FAP Clinical Contact Note
Case Number 92280 Client Name:

(b)(6)

Contact Date: 1/19/201 0

Clinical Provider:

Time Spent: 0

Type of Contact: Email

(b)(6)

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summary of Contact:
(b)(6)
'

(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

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1/7 /?0 1 1

Clinical Contact Note
(b)(6)

Case Number 92280 Client Name:
Contact Date: 1/21/2010
Time Spent: 0
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

jType of Contact: In Person
jType of Session: Group

Session Notes:
Group Note/Participation Form
Date: 1/21/10 Client's Name:
(b)(B)
Group Name: FALCON Group Leader(s):
Session# 4

1Case Manager:
~)&>)

(b)( 6 l

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+
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)( l
participated in group check-in exercise and stated that all was well with him: no
significant conflicts in his personal life. Durinq a group discussion/exercise on how members
6
feel, react and behave when angry,
(bl( l
was quiet Rlthnugh he appeared attentive and
6
focused on the discussion during most of the group.
(b)( )
did not have any responses or

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Clinical Contact Note
Case Number 92280 Client Name:

(b)(6)

Contact Date: 1/28/201 0
Time Spent: 0
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

/Type of Contact: In Person
/Type of Session: Group

Session Notes:
Group Note/Participation Form
6
Date: 1/28/10 Client's Name:
(b)( )
~ase Manager:
Group Name: FALCON Group Leader(s): ·~)~) Session# 5
·

(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 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

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FAP Clinical Contact Note
Case Number 92280 Client Name:

(b)(6)

Contact Date: 2/4/2010

Clinical Provider:

Time Spent: 0

Type of Contact: Email

(b)(6)

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summary of Contact:
Dear Madam,

(b)(6)

Division Officer aboard USS KIDD (DOG 100) here on 32nd
I am
Street Naval Station San Diego. It has been brought to my attention that I am to inform you
(b)(6)
will be unable
that our ship will be at sea for the period of 4 February 2010, thus
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

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Clinical Contact Note
Case Number 92280 Client Name:

(b)(6)

Contact Date: 2/11/201 0
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

IType of Contact:

In Person

IType of Session: Group

Session Notes:
Group Note/Participation Form
Date: 2/11/10 Client's Name:
(bl{ 6 l
Case Manager:
Group Name: FALCON Group Leader(s)~ ~)~)
Session# 6

(bl( 6 l

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.

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Clinical Contact Note
(b)(6)

Case Number 92280 Client Name
Contact Date: 2/19/2010
Time Spent: 0
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

!Type of Contact: In Person
!Type of Session: Group

Session Notes:
Group Note/Participation Form
Date: 2/18/10 Client's Name:
(b)( 6 l
Group Name: FALCON Group Leader(s):
Session # 7 of 8

Case Manager:

(b)(B)

~j [v)

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.

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Clinical Contact Note
Case Number 92280 Client Name:

(b)(6)

Contact Date: 2/25/2010
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

\Type of Contact: In Person
\Type of Session: Group

Session Notes:
Group Note/Participation Form
6
Date: 2/25/10 Client's Name:
{b)( )
Case Manager:
Group Name: FALCON Group Leader(s): (_b)(~&>)
Session# 8

(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.

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Clinical Contact Note
Case Number 92280 Client Name:

(b)(6)

Contact Date: 3/4/2010
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

JType of Contact: In Person
jType of Session: Group

Session Notes:
Group Note/Participation Form
6
(b)( )
Case Manager: (b)(6 )
Date: 4 MAR 10 Client's Name:
Group Name: FALCON Group Leader(s): (_b)~) , Session# 9 of 8

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
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)( )
was on time to group. He left group two times without explanation. He also appeared
to fall asleep for a moment. He said things were going ok for him and nothing was new. He is
not in a relationship at this time.
The group focused on Chapter 6, Thoughts and Behaviors. The group discussed control. That
pushing your will on another does not work well. During group his participation was not
involving or engaging in the discussion.
(b)( 6 )
was quiet .and did not actively participate in
group exercise/discussion about control in relationships.
(b)(6)

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FAP Clinical Contact Note
{b){6)

Case Number 92280 Client Name:
Contact Date: 3/9/2010

Clinical Provider:

Time Spent: 0

Type of Contact:

(b){6)

Collateral Contact:
Summary of Contact:
Dear Madam,
(b)(6)
J~)&)
lam
Division Officer aboard '
(b)(6)
Street Naval Station San Diego. Our ship is currently at sea and
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:

IDate of Signature: 3/18/201 0

(b)(6)

JT"

A

T'\~1'

1"\.T

here on 32nd
will not be

1

FAP Clinical Contact Note
(b)(6)

Case Number 92280 Client Name:
Contact Date: 4/5/2010

Clinical Provider:

Time Spent: 0

Type of Contact: Email

(b)(B)

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summarv of Contact:
(b)(B)
Dear
I really appreciate your response and attention to this matter.
(b)(B)
complete 8 sessions of Men's Group
The CRC actually recommended that
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.

Officially we could close this case as Resolved because he completed CRC
recommendations.
We were attempting to work with the SM to make life a little easier for him.
Let me know if you would like me to keep the case open to accommodate his civilian
obligations.
Thank you again.
Sincerely,
(b)(6)

FAP Case Manager

I619-556-8815

(b)(6)

-----Oria ina I M essaae----(b)(6)
From:
Sent: rndav. Aoril 02.2010 16:f>R
To:
(b)(6)
Cc:
(b)(Bl
Subject: RE: Continued Group Absence-

(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 ·'

FAP Clinical Contact Note
(b)(6)

Case Number 92280 Client Name:
Contact Date: 4/5/2010

Clinical Provider:

Time Spent: 0

Type of Contact: Email

(b)(e)

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summary of Contact:
Dear

(b)( 6 l

I know this is confusing.
He will need an additional44 sessions to fulfill civilian obligations. He may continue to do an
additional 18 sessions here; as our program is 26 weeks and he has already done eight of
those 26. As I stated, the benefit to the SM is that he does not have to pay out of pocket for at
least half of what the court is requiring.
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.
Please keep me informed of your decision.
Sincerely,
(b)(6)

FAP Case Manager
619-556-8815
(b)(6)

-----OriainAI MA~!'::Rm=•----From:
(b)(6J
Sent: lv1onaay, APnl uo, ~U1U 9:55
To:
(b)(6)
SubJect: RE: Continued Group Absence .

(b)(6)

(b)(6)

It sounds like this is more of a multidimensional case than I thought.
1. So how many more FAP sessions does he need to fulfill his
civilian obligations?
2. On what level can the case be closed now?
3. What do have to do close the case once and for all?
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)

~)~)

'

--,

Work: 619-556-3802 ext. 41 01/4103

-----Oriqinal Messaqe----From
Sent: Thursday, April 01, 2010 3:57 PM
To:
(b)(6)
Cc:
(b)(6)
Subject: Continued Group Absence -

(b)(6)

(b)( 6 l

(bl( 6 l

Dear
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.
(b)(

Thank you,
(b)(6)

FAP Case Manager
619-556-8815
(?~)
(b)(6)

SIGNATURES
Signature of Provider:

t. . H.,.....,,/f-(.;·.r,., •....-.:,.

.-..-.. :r-

...,.,,,.,,

IDate of Signature: 4/5/2010

(b)(6)

_...: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)

Work: 619-556-3802 ext. 4101/41 03

----Orioinal Messaae---From:
Sent: Monday, Apnl 05, 2010 8:48AM
To:
(b)(6l
Subject: RE: Continued Group AbsenceDear

(b)(6)

(b)(6)

(b)( 6 l

I really appreciate your response and attention to this matter.
6
The CRC actually recommended that
(bl( l
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 F AP Program. We were
willing to accommodate his request, as the groups out in town cost $25 to $40 per week.
We provided
(b)( 6l
with a letter to the court asking that he be allowed to complete
the 26 week program at FAP and they agreed.

Officially we could close this case as Resolved because he completed CRC
recommendations.
We were attempting to work with the SM to make life a little easier for him.
Let me know if you would like me to keep the case open to accommodate his civilian
obligations.
Thank you again.
Sincerely,
(b)(6)

FAP Case Manager
619-556-8815
(b)(6)

-----Oria ina! Messaae----From:

(b)(6)

rage:

Sent Friday, April 02, 2010 16:58
To:

,J Ul .J

(b)(6)

Cc:
(b)(6)

Subject: RE: Continued Group Absence (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
I

RP.~nAr.tftlllv
(b)(6)

(B)L<o}

'

.

Work: 619-556-3802 ext. 4101/4103

-----Orin in~l

M~=>c::c::;::ln~=>---­

From:
Sent: 1nursoay, Apnl 01, 201 o 3:57PM
To:
(b)(6)
Cc:
Subject: Continued Group Absence-

Dear

(b)(6)

(b)(6)

(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)

FAP Case Manager
619-556-8815
(b)(6)

SIGNATURES
Signature of Provider:

(b)(6)

IDate of Signature: 4/5/2010

Clinical Contact Note
Case Number 92280 Client Name:

(b)(6)

Contact Date: 4/15/2010
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group
Session Notes:
Group Note/Participation Form
Date: 4/15/10 Client's Name:
(b)(S)
Case Manager:
Group Name: FALCON Group Leader(s)(blJ
Session# 10

jType of Contact: In Person
!Type of Session: Group

(b)(S)

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
Case Number 92280 Client Name:
Contact Date: 4/22/2010
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

(b)(6)

!Type of Contact: In Person
!Type of Session: Group

Session Notes:
Group Note/Participation Form

Case Manager: (b)(6 )
Date: 4/22/1 0 Client's Name:
(b)( 6 l
Group Name: FALCON Group Leader(s): (b)(<P)
Session# 11
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 a new member.
(b)( 6)
completed the homework on core beliefs, automatic thoughts and self talk. He was quiet
during group. Group facilitators met with him after group to discuss his lack of participation
and to ask about any difficulties or needs he was having relative to the materials or group
6
(b)( J
stated that he is very shy and has a hard time speaking up. He also said
process.
that the material and discussions were sometimes beyond his ability to grasp. Facilitators
encouraged his ongoing participation and agreed to draw him out more during sessions.

I <lt:;l:-

J Ul L

Clinical Contact Note
(b)(6)

Case Number 92280 Client Name:
Contact Date: 5/20/2010
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group
Session Notes:
Group Note/Participation Form

6
(b)( l
Case Manager:
Date: 5/20/10 Client's Name:
Group Name: FALCON Group Leader(s): Q:>)(c,)
Session # 14 of 26
Content of Group:
(1 =none; 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 3 Motivation for Change 3
Personal Disclosures 3 Insight & Self .A.wareness into
Behavior 3
Empathy for child and/or others 3- Respectful attitude 4
Knowledge & Understanding of
Anger Management Strategies 3 Overall Participation 3-

jType of Contact: In Person
jType of Session: Group

(b)(6)

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 X Increased Stress
Inappropriate Other_ _ _ _ _ _ _ __
Flat None X
Angry
Sad
Anxious
Confident
Regretful
Other
Additional Comments or Closing Summary:
(b)(6J
was on time for group. He continued to stay in the group throughout the meeting. He
passively participated in a curriculum review exercise as well. When called upon to contribute
he appeared not to understand the material.

(b)(6)

r /-\ltereci Trcatrnent Pl<m

Plan Status (.) Continue-: Treatrnent Pian
Diagnostic Impression r- Uncnarl£J0KJ
Recommended Referrals:

If'

((;

f<ev1~;ecJ

\._...-IIIIIL.(ll

\._.,\.1Ullt"\l,.,...llJlE LVJllUVl l"iVt\...

Clinical Contact Note
Case Number 92280 Client Name:
Contact Date: 6/3/201 0
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

(b)(6)

jType of Contact: In Person
jType of Session: Group

Session Notes:
Group Note/Participation Form
Date 6/3/10
(b)( 6 )
Client's Name:
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.

(1 =none; 2=rarely;3=sometimes;4=often;5=very often; NA=Not Assessed)
Acceptance Of Responsibility 4 Motivation for Change 3
Personal Disclosures 3 Insight & Self Awareness into
Behavior 3
Empathy for child and/or others NA Respectful attitude 5
Knowledge & Understanding of
Anger Management Strategies 3 Overall Participation 3
AFFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded X Suicidality
Resentful Increased Risk of Re-abuse
Calm X Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective X Increased Stress
Inappropriate Other_ _ _ _ _ _ _ __
Flat None X
Angry
Sad
Anxious
Confident
Regretful
Other Shy
Additional Comments or Closing Summary:
6
(b)( )
was the first member of group to share homework assignment.

(b)( 6 )

has a

rage

L. UJ L

noticeable increase in participation and is attempting to apply information despite not having a
6
(b)( )
will occasionally share oersonal information but rarely
current relationship.
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)

Plan Status

(<?' Co11tw,u1:~ -~reatment

Diagnostic Impression

r

Recommended Referrals:
In-House FFSC:
FAP
SIGNATURES
Signature of Provider:

F'lan

Llnchanged

("

1\iter~-;cj

""'~-, l ,_

c;; f<CVISNi

/External Military:

(b)(6)

:, ,,-r.·....... a,
.,rr-n>"f11
F i a 11
-

/External
Civilian:

\ Date of Signature: 6/9/201 0

'Tri-Care:

l

a::;\...

J UJ

Clinical Contact Note
Case Number 92280 Client Name:

(b)(6)

Contact Date: 5/13/2010
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group
Session Notes:

/Type of Contact: In Person
/Type of Session: Group

Group Note/Participation Form
Date: 5/13/10 Client's Name:
(b)(B)
Case Manager:
Group Name: FALCON Group Leader(s):. (p)(&)
Session# 13
Content of Group:
(1 =none; 2=rarely;3=sometimes;4=often;5=very often)
Acceptance Of Responsibility 3 Motivation for Change 3
Personal Disclosures 3 Insight & Self Awareness into,
Behavior 3
Empathy for child and/or others 3- Respectful attitude 4
Knowledge & Understanding of
Anger Management Strategies 3 Overall Participation 3-

(b)( 6 l

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 X Increased Stress
Inappropriate Other~-------­
Fiat None X
Angry
Sad
Anxious
Confident
Regretful
Other
Additional Comments or Closing Summary:
(b)(B)
was on time for group. He continued to stay in the group throughout the meeting. He
passively participated in a group introduction exercise with a new member, and passively
participated in a curriculum review exercise as well.
(b)(6)

Plan Status w C;onirnue ·1 teatrnent F'iap
Diagnostic Impression r Uncl1:::mged
Recommended Referrals:
In-House FFSC:
j External Military:

!External

ITri-Care:

L

FAP Clinical Contact Note
Case Number 92280 Client Name:

(b)(

6

l

~------------------------------~--------------~------------------~

Contact Date: 6/9/2010

Clinical Provider:

Time Spent: 0

Type of Contact: Email

(b)( 6 l

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summarv of Contact:
Hi

(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,

Let me know if you have any questions,
Sincerely,
(b)(6)

Fleet and Family Support Center, Village of Serra Mesa
3141 Afton Road
San Diego, CA 92123
(619) 805-5800
(b)(6)

SIGNATURES

Signature of Provider:

(b)(6)

JDate of Signature: 6/9/2010

Clinical Contact Note
Case Number 92280 Client Name:
Contact Date: 6/17/2010
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

(b)(6)

jType of Contact: In Person
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.
(1 =none; 2=rarely;3=sometimes;4=often;5=very often; NA::;Not Assessed)
Acceptance Of Responsibility 3 Motivation for Change 2
Personal Disclosures 2 Insight & Self Awareness into
Behavior 3
Empathy for child and/or others 2 Respectful attitude 5
Knowledge & Understanding of
Anger Management Strategies 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 None X
Angry
Sad
Anxious
Confident
Regretful
Other Fatigued
Additional Comments or Closing Summary:

(b)(6)
was noticeably fatigued at group.
stated to group that he has been ill and
fell asleep repeatedly throughout group processing.
(b)(6)

(b)(6)

Plan Status (; .:orm:·!W
' ..... -·
'

'rc·:Jl'JiC'li
' ' -· ... '- .
·• .;:·~i::on
,_,
~

( /.Jtel't:d 'i'rE'i'\l!llellt r\an

« F<.ev:c:;t::d
Diagnostic Impression r J ndi <m~wc!
Recommended Referrals:
In-House FFSC:
'External Military:
FAP
SIGNATURES

!External
Civilian:

------~---

Signature of Provider:

(b)(6)

I Date of Signature:

6/21/2010

ITri-Care:

I

1 r\1

L·lltiiVUl

\.._,\.JitlU\...1.. 1..,-\Jl.\,.

FAP Clinical Contact Note
Case Number 92280 Client Name:

(bJ(Bl

Contact Date: 6/21/2010

Clinical Provider:

Time Spent: 0

Type of Contact: Email

(b)(6)

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summary of Contact:
(b)(6)

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)

Fleet and Family Support Center, Village of Serra Mesa
3141 Afton Road
San Diego, CA 92123
SIGNATURES
Signature of Provider:

tlt'H.''.r/ff-Cn""l;C'

r-n;ro n r n ' ' '

(b)(6)

-n""';I/ ..... ,....,.., .............................. ~L'/1'......... ~--··'r

/ Date of Signature: 6/21/201 0

1\ Df"'l: .• :

.ll.T

n

r·r\r

\.._.!Jllll..c.U \....-Ul!LaL>t J'fUtc:

FAP Clinical Contact Note
(b)(6)

Case Number 92280 Client Name:
Contact Date: 6/22/2010

Clinical Provider

Time Spent: 0

Type of Contact: Email

{b){ 6 l

Collateral Contact: GOVERNMENT AGENCY/ORGANIZATION
Summary of Contact:
(b)(6)

was Excused on 17 June 2010.

(b){6)
(b)(6)

Fleet and Family Support Center, Village of Serra Mesa
3141 Afton Road
San Diego, CA 92123
(619) 805-5800
(b)(6)

From:
(b)( 6 )
Sent: Tue 6/22/2010 7:40AM
To:
Subject: For Official Use Only

{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)

Family Fleet & Support Counseling Center
3135 Dolphin Alley, Bldg 261
Naval Base San Diego, CA
Office 619-556-9269
Fax 619-556-9678
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:
Contact Date: 6/24/2010
Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

(b)(6)

!Type of Contact: In Person
!Type of Session: Group

Session Notes:
Group Note/Participation Form
Date: 6/24/10
(b)(6)
Client's Name:
Case Manager:
(b)( 6 )
Group Name: FALCON
(b)(6)
Group Leader(s):
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 ~~~)

(1 =none; 2=rarely;3=sometimes;4=otten;5=very often; NA=Not Assessed)
Acceptance Of Responsibility 2 Motivation for Change 2
Personal Disclosures 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

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 X
Angry
Sad
Anxious
Confident
Regretful
Other Disinterested
Additional Comments or Closing Summary:
(b)(e)
continues to have minimal participation in group. (_.6~) . when confronted,

lexpla1ned that inforrnatlon w111 be relevant when he becomes Involved in another dating
\relationship.
(b)( 6 ).
remains disengaged from group discussion. It remains difficult to gauge

111is learning and ins1ght.
I

L._
(b)(6)

External Military:

(b)(6)

of Signature: 6/25/2010

https. / smis.cnic.navy .mi Vcomponents!forms~CiinicalContaciNoteReport.aspx?i\pplicalio...

I /7.<20 I I

Page 9 of <f(,

nical Contact Note
(b)(6)

of Contact: In Person

(b)(6)

Case tv1anager(b)( 6 )
(b)(6)

Cypress Group LeadDr(s):

Chapter 15 Chnng1n9 House rules

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----·-···-····

External Military:

(b)(6)

External Civilian:

Tri-Care:

________ IDate of Signature: 11/23!2010

·(fsmi s.cn i c .navy nti !/components/ forms 1PnntA Ilr onns.aspx

12112/20 I 0

Page 12 of 46

I
,Clinical Contact Note
(b)(6)

' ase Number 110007 Client Name:
' ontact Date: 11110/2010
; ime Spent: 1.5
umber of Individuals Seen: 1
; ype of Counseling Group: Offender Group

1Type of Contact: In Person
!Type of Session: Group

ession Notes:
roup Note/Participation Form
(b)(6)

ate: Nov 10,2010 Client's Name:

,( roup Name: Cypress Group Leader(s):

Case

Manager:~"kl

(b)(6)

·£ ession # 5
Content of Group: Chapter 14- Social Values
( =none; 2=rarely; 3=sometimes; 4"'often; 5=very often)

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
A FECT THERAPEUTIC CONCERNS
L.J beat xxx Incident of Re-abuse
G arded Suicidal
R sentful Increased Risk of Re-abuse
C lm x Hostile, Aggressive Behavior
Frflslrated Increased Depression
R4 flective x Increased Stress
In ppropriate Other
Fl t None x
Arjgry

s~~

Ar ious
c<rfident
Rt~retful

Ot er
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 '

Di< !gnostic Impression
Re ommended Referrals:

.

'o~ -~

,y '-

PitT~

df ~~~ ;_ '.._\

"·'·' .:z; .

!

~~

r·) :~i 1 i

'-:-. \'J'''·"

IExternal Military:

In· ~ouse FFSC:

:...:·!!!',-'

.!External Civilian:

SlPNATURES
Si~nature of Provider:

l

(b)(6)

j Date of Signature: 11/18/2010

jTri-Care:

Clinical Contact Note
(b)(6)

Contact:

GOVER~~MENT

AGENCY iORG.ANIZATION

of Contact:
SM and discussed upcomin9 CRC. SM is 111 a 52 wk program ordered by the court. He believes he h8S
about 10 weeks; but will request n progress report tram SBCS when he goes tomorrow night lo nroup. Client
sevo1 al questions regardin9 the possible outcome of the Cf~C tomorrow. Th1s CM explained the voting procedure and
possible outcome and recommendations If substantlilted. SM was under the impression that !he decis1ons made at
Mass had taken care of the situation and was frustrated that so many things wore still in the balance. Th1s CM told
the dec1sion of tho CF<'.C would be ernailed to 111111 and that a letter would go to h1s command within 2 weeks. Client
individual counsel1ng as well Cl1enl reported that he does not dnnk anymore nt all nfter this last inc1dent. Client
rem1nded that he could cma1l a summary statement for the CRC tomorrow if he c11ose.

of Signature: 8/17/2010

Ill!

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Page 2 of30

- - ---. - -

'

Clinical Contact Note
(b)(6)

Case Number 111365 Client Name:
Contact Date: 11/18/2010

IType of Contact: In Person

Time Spent: 1.5
Number of Individuals Seen: 0
Type of Counseling Group: Offender Group

!Type of Session: Group

; Session Notes:
Group Note/Participation Form
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
· (1 =none: 2=rarely; 3=sometimes; 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
~ffective Parenting Strategies N/A
Notivation for Change 3
nsight & Self Awareness into
Behavior 2
Respectful attitude 4
:Jverall Participation 2
~FFECT

THERAPEUTIC CONCERNS
~pbeat Incident of Re-abuse
~uarded X Suicidal
~esentful Increased Risk of Re-abuse
-:aim Hostile, Aggressive Behavior
rustrated Increased Depression
· Reflective Increased Stress
•lflappropriate Other
lat None
ngry
ad
f.nxious
onfident
egretful
ther:
. dditional Comments or Closing Summary: Client shared for the most part only when called on one time toward the
~ginning. It is difficult to read client in some of the above categories because he did not share very much in the group today.
I< lient was following along in the book. Client will hopefully open up more as he attends more group sessions and gets more
cpmfortable.

It

IF Jan Status . ·rr r;tF
IGiagnostic Impression

·;,·

':-~

-.

·l

~;;

F~a'

:1; ; ;,j r:.; ~1

jecommended Referrals:

/--'1{-r(.-

) r ~(<;?tP:;_'<''d F'·;.·n

':,(·,.'l~'l(~\

I

It -House FFSC;

External Military:

F~P

i>IGNATURES

S gnature of Provider:

;

(b)(6)

!External Civilian:

ITrf-Care:

l

Date of Signature: 11/19/2010

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121221201 n

Page 3 of30

Clinical Contact Note
(b)(6)

Case Number 111365 Client Name:
Contact Date: 11/8/2010
Time Spent: 1.5
Number of Individuals Seen: 0

!Type of Contact: In Person

Type of Counseling Group: Offender Group

!Type of Session: Group

Session Notes:
Group Note/Participation Form
Date: 28 Oct 10
(b)(6)
Case Manager:(b)(B)
Client's Name:
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
fc\FFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
3uarded Suicidal
Resentful Increased Risk of Re-abuse
Calm X Hostile, Aggressive Behavior
rustrated Increased Depression
~eflective Increased Stress
nappropriate Other
Ia! None
ngry
ad
nxious
onfident
egretful
ther:
• dditional Comments or Closing Summary: The client attended his first DV offender group and was quiet throughout unless
sked to participate. He shared personal information about the incident that got him placed in group when asked.
Jan Status

/"·' .'ll'·f',·,Ji.

It iagnostlc Impression

··;;~J:n::.:n:

,!\ •

'

ecommended Referrals:

>1;;H-l

~~\fi~J<<~

~'"'\!tcrL:_,
~-~ i

;;(1;f:;t;·

t

.1 .~:a\;

··".t\:-;r···

IExternal Military:

l -House FFSC:
1FAP

!External Civilian:

ITri-Care:

. ~IGNATURES

f ignature of Provider:

(b)(6)

IDate of Signature: 11/812010

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J 2/??1?01 n

Page 4 of30

Clinical Contact Note
(b)(6)

Case Number 111365 Client Name:

---

Contact Date: 11/4/2010
Time Spent: 1.5
Number of Individuals Seen: 0

jType of Contact: In Person

Type of Counseling Group: Offender Group

jType of Session: Group

Session Notes:
Date: 11/04/10
(b)(6)
Case Managedb)(6)
Client's Name:
Group: 2
~
Group Leaders:
(p)
Content of Group: hap. 9 Solve your Problems

(£> (

(1 =none; 2=rarely; 3=sometimes; 4=otten: 5=very often)
1 2 3 4 5 NIA
Acceptance Of Responsibility 3
Personal Disclosures 3
Empathy for child and/or others 3
Knowledge & Understanding of
Effective Parenting Strategies N/A
· Motivation for Change 3
Insight & Self Awareness into
. Behavior 3
• Respectful attitude 3
· Overall Participation 3
AFFECT THERAPEUTIC CONCERNS
Upbeat Incident of Re-abuse
Guarded Suicidal
Resentful Increased Risk of Re-abuse
Calm X Hostile, Aggressive Behavior
rustrated Increased Depression
Reflective Increased Stress
nappropriate Other
lat None
... ngry
3ad
i'nxious
. onfident
~egretful

)!her:
dditional Comments or Closing Summary: Client participated during discussion and seemed to be taking notes and actively
I stening. Client shared how he has learned to be patient with his wife and not push the issue and give her space to come to
im to talk when she is ready. Client gave helpful feedback to other group member.

'F ian Status

·... :n ;:t: ;h

!

Ciagnostic Impression

..

'-!' ,. ", . :.;,

.

'.

.f ecommended Referrals:

'f';,.··'

;.,!!('

·.. · u· -1:n·•·:

·

'I"

''·

C\'-._·',!1,;.. (.·~

I

l

-House FFSC:
Ff\P

External Military:

!External Civilian:

ITri-Care:

~IGNATURES
~

ignature of Provider:

(b)(6)

) Date of Signature: 11/912010

.

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. FAP Clinical Contact Note
· Case Number 111365 Client Name:

(bJ(6J

Clinical Provider:

, Contact Date: 10/25/2010
Time Spent: 0.5

(b)(6)

Type of Contact: Phone

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:

JJf'r

(b)(6)

Date of Signature: 10/25/2010

o l 30

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Page 6 of30

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FAP Clinical Contact Note
~ase Number 111365 Client Name:

(b)(6)
(b)(6)

Contact Date: 10/8/2010

Clinical Provider:

Time Spent 1.5

Type of Contact: In Person

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

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12/22/2010

Page 10 of 30

Collateral Contact Note
Case Number 111365 Client Name:

(b)(6)

j Clinic;! Provider:

Contact Date: 9/28/2010

j Time Spent: 0.25

(b)(6)

CONTACT
Contact Name:

(b)( 6 )

Collateral Contact: GOVERNMENT
~GENCY/ORGANIZATION

j Type of Contact: Email

Contact Notes:
-----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.
rhanks, again. for your help.
(b)(6)

----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

(b)(6)

in the Cypress group. I took (b)( 6 ) place abou

month ago (b)(6)

- --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

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Page 11 of 30

\Collateral Contact Note
Case Number 111365 Client Name:

I

· Contact Date: 9/28/2010

(b)(B)
(b)(6)

Clinical Provider:

ITime Spent:

0.25

~-~~-----------J..----------t

CONTACT
Contact Name:

(b)(B)

Collateral Contact: GOVERNMENT
AGENCY/ORGANIZATION
Contact Notes:
(b)(B)
CNRSW, N91
From:
"To
(b)(6)
NSWC Corona, FT24
Sent: 1 ue Sep 28 15:48:00 2010
Subject:

I

Type of Contact: Email

Hi (b)(6) I am trying to see if you are the CM for a fellow in our DV aroup. He is name is
him yet. Could you let me know if he is one of yours. Thanks (b)(6)

(b)(6)

and we haven't seen

(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

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linical Contact Note
(b)(6)

Number 60118 Client Name:

of Contact:
of Session:
,

ssion Notes:

(Group Note/Participation Form
~ate: 9 Dec 09 Client's Name:

(b)(6)

~roup Name: Cypress Group Leader(s):

Manage1

(b)(e)

(b)(e)

ifession # 15
Content of Group: Review of "The box" and relapse prevention
1=none; 2=rarely; 3=sometimes; 4=often: 5=very often)
~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

fljFFECT THERAPEUTIC CONCERNS
l.Jpbeat xxx Incident of Re-abuse
jGuarded Suicidal
IResentfulln~reased Ris~ of Re-abuse
·Qalm x Hostile, Aggressive Behavior
Frustrated Increased Depression
Reflective x Increased Stress
lriappropriate
Flat None x

Ahgry
Shd
Anxious
Confident
Rfgretful
Other

I

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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

External Civilian:
!Signature of Provider:
!Signature of Supervisor:

(b)(6)
(b)(6)

Tri-Care:

Date of Signature: 12/22/2009
Date of Signature: 1/6/2010

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]/7/201

J

finical Contact Note
(b)(6)

of Contact:
of Session:
Notes:
Note/Participation Form
9 Dec 09 Client's Name:

(b)(6)

Cypress Group Leader(s)·

Manager:

(b)(G)

(b)(6)

Content of Group: Review of "The box" and relapse prevention

'1 =none; 2=rarely; 3=sometimes; 4=often; S=very often)
tf\cceptance Of Responsibility 3
~"ersonal Disclosures 3
[j:mpathy for child and/or others 3
}Knowledge & Understanding of
t;:ffective Anger Management Strategies
. Motivation for Change 3
Insight & Self Awareness into
E~ehavior
Respectful attitude 4
Overall Participation 3
AFFECT THERAPEUTIC CONCERNS
Upbeat xxx Incident of Re-abuse
Guarded Suicidal
fiesentfullncreased Risk of Re-abuse
Qalm x Hostile, Aggressive Behavior
Frustrated Increased Depression
R;eflective x Increased Stress
lqappropriate Other
F!at None x
Ahgry
Sad
Anxious
Confident
Regretful
Other

,
I

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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

External Civilian:
(b)(6)

of Supervisor:

Tri-Care:

of Signature: 12/10/2009
(b)( 6 )

Date of Signature: 12/14/2009

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1/7:2011

Clinical Contact Note
(b)(6)

Number 60118 Client Name:

of Contact:
of Session:
Session Notes:
Date: Sep 30, 09 Client's Name:

(b)(6)

Group Name: Cypress Group Leaden's):

Manager:

(b)(6)

(b)(6)

Session# 12
Content of Group: Conflict Resolution
(I =none; 2=rarely; 3=sometimes: 4=often. 5=very often)

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
ECT THERAPEUTIC CONCERNS

Anx1ous
confident
1Regretful
Other

I

Additional Comments or Closing Summary:

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was very reserved th1s week. He was attentive; but did not participate much as 2 new
did most of the

External Military:
Signature of Provider:
Signature of Supervisor:

External Civilian:

re:

(b)(6)
(b)(6)

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li ical Contact Note
(b)(6)

Number 60118 Client Name:

of Contact:
of Session:

: Sep 2, 09 Client's Name:
Group Narne: Cypress Group Leader(s):

Manager

(b)(G)

(b)(6)

I

Sess1on # 11
Content of Group. Physical Cues of Anger
1=none: 2==rarely; 3=sometimes; 4=often; 5==very often)

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

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itional Comments or Closing Summary:
was able to identify 3 physical cues occurring in his body when he get angry.
and active in
discussion this week.

External Civilian:
(b)(6)

of Supervisor:

(b)(6)

re:

of Signature: 9/4/2009
of Signature: 12i8/2009

'ITsm is.cnic.nav~ .m i ]/com ponents/l'orms/Pri ntAll FornJs.aspx

1.7/2011

linical Contact Note
(b)(6)

Number 60118 Client Name:

of Contact:
of Session:
Notes:
Group Note/Participation Form
Date: ,L\ug 12, 09 Client's Name:

(b)(6)

Name: Cypress Group Leader(s):

Manager:

(b)( 6 )

(b)(6)

#iO
[content of Group Masculinity Traps
i

[(1 =none, 2=rarely, 3=sometimes: 4=often, 5=verf often)
f

!Acceptance Of Responsibility 3
!Personal Disclosures 3
Empathy for child and/or others 3
)Knowledge & Understanding of
jEffect1ve Anger Management Strategies

IG

'!Motivation for Change 3
,Insight & Self Awareness into
/Behavior
13
/Hespectful attitude 4
Overall Participation 4
ECT THERA.PEUTIC CONCERNS
Upbeat xxx Incident of Re-abuse
Guarded x Suic1dality
Resentful Increased Risk of Re-abuse
Calm Hostile, Aggressive Behavior
Frustrated Increased Depression
F~eflective Increased Stress
rnappropriate
None x

Anxious
Confident x
F~egretful

Other

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1'7;20 11

itronal Comments or Closing Summary:
ient reported that he is not serious about anyone. He agreed with the group that he does
share himself
with a
because he sees it as a weakness and u

External Civilian:
(b)(6)

ht

Tri-Care:

of Signature: 8/13/2009

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I Contact Note
Number 60118 Client Name:

(b)(6)

of Contact:
of Session:
Notes:
Group Note/Participation Form

5 ;\ug 09 Client's Name:

(b)(6)

Group Name: Cypress Group Leader(s):

Case Manager:
(b)(6)

Session# 9
Content of Group: Recognizing Triggers
(1 ::::none; 2::::rarely: 3=sometimes; 4=often. 5=very often)
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
ECT THEr:;;APEUTIC CONCERNS

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(b)(6)

i.I.S,'-

l ·-'

\JJ

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Comments or Clos1ng Summary:
shared his incident that brought him into group. Client reported he is no longer with that
partner: but he regrets the choices he made that day. He admitted he was irntated with the
hbor who called the
and ·embellished' on the
---------~---------------------

Status

. ----·------·------1

External Civilian:
(b)(6)

Date of Signature: 8/13/2009

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lin i

ntact Note
(b)(6)

of Contact:
of Session:
Notes:
Note/Participation Form
24 June 09 Client's Name:

(b)(6)

p Name: Cypress Group Leader(s)

Case Manager:

(bl( 6 l

(b)(6)

of Group·
on recognizing & setting boundaries with others using "I statements" as well
as recognizing & accepting their partner's differences.
!=none, 2=rare!y; 3=sometimes; 4=often; 5=very often)
.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

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rage 1 o

01

::u

Regretful
Other
Comments or Closing Summary·
was a little on the quiet side today He was attenttve and gave feedback vvhen asked.
idea 1s to
back whatever
as a
to teach the other a lesson.

External Military:
(b)(6)

External Civilian:

Signature: 7/31/2009

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1/7/201!

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linica! Contact Note
Number 60118 Client Name:

(b)(6)

Provider:

(b)( 6 )

-----

of Contact: In Person

(b)(6)

Date of Signature: 7/10/2009

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lf7i2()l1

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I C ntact Note
Number 60118 Client Name:

(b)(6)

of Contact:
of Session:

: 17 June 09 Client's Name·

(b)(6)

Case manager:

Group Name: ____ Cypress _______~_ Group Leader(s):

(b)(6)

(b)(G)

Session# 7
Content of Group: Revenge

. 1=none, 2=rarely; 3=sometimes; 4=often; 5=very often)
1
I 234 5
i\cceptance Of Responsibility 4
Personal Disclosures 4
IEmpathy for child and/or others 3
jl<:nowledge & Understanding of
Parenting Strateg1es 3
rv1otivat1on for Change 4
/Insight & Self Awareness into
Behavior 4
F<espectful attitude 4
Overall PartiCipation 4

I

AFFECT THERl\PEUTIC CONCERNS
Upbeat Incident of Re-abuse
C?uarded Suicidality
F~esentful Increased Risk of Re-abuse
x Hostile, ,t.,ggressive Behavior
Frustrated Increased Depression
Fzeflective x Increased Stress

Confident
Regr·etful
Other

Imp~;.

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l /7.'2011

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i:;,dditional Comn1ents or Closmg Summary:
continues to do well in group and 1s engaged m the process. He enthusiastically made
two absences in 1nd1vidual sessions, picking the topics and working through the issues. He
as genuinely interested in building equtty in his relationship.

(b)(Gl

External Civilian:
(b)(6)

Tri-Care:

of Signature: 6i22/2009

1rsm is.cnic .nm·y.m i 1\:omponentsforms/Pri ntA II Fonns.asp.x

]/7//..f) J 1

lini

ontact Note
Number 60118 Client Name:

(b)(6)

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

External Military:
(b)(6)

External Civilian:

Tri-Care:

of Signature: 6/1212009

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l if/20 I J

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!Clinical Contact Note

~~~c~~~!,~~~~~a_m~

(b)(6i

[!'ime Spent: 0 __
_________________ J!ype _?f Contact:
~Number of Individuals Seen: 0

~pe of Counseling Group:

.

-~

_______ _

___ jType of Se~sion:____________._

lSession Notes:
flc;roup Note/Partic1pat1on Form

II

!Fate· 9 Dec 09 Cl1ent's Name

6
(b)( J

jproup Name: Cypress Group Leader(s).

~-1a nage

(b)( 6 )

(b)(6)

!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

1fersonal Disclosures 3
ll~mpathy for child and/or others 3
jt~nowledge & Understanding of
$.• ffective Anger Management Strategies
1

!=~

/lv{1otivat1on for Change 3
lipsight_ & Self /\ware ness into
E?ehavJor

3
IF~espectful
attitude 4

II<~verall
I

Participation 3

/tiFFECT THERAPEUTIC CONCERNS

dpbeat xxx Incident of Re-abuse
quarded Suicidal
1Rjesentful Increased R1sk of Re-abuse
1
lc!airn x Hostile, Aggressive Behavior
Frustrated Increased Depression
!Reflect1ve x Increased Stress
/lrjappropriate Other__________
1F!at None x
I ,,;_,gr'
l''""'ll j
1Sad
J

1

I

i "-:

.

ik':JXIOUS

IC.bnfiden t
!Regretful

/Olher
1

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il

lClient vvas attentive and participated a little. He \Nil! complete group next week.
!Client ga·.;e some feedback to those graduating when they shared their relapse prevent1on

i~dditlonal Comments or Closing Summary:

ttliS

!Plan
------- ------ --------------------------------------:Plan Status ·
' .
, ,
'
' ;
lbi~g~~stic lr;p-ression
-----------·
~--

iR~~ornme~-d~d-Referr~!s:

----~-----

1-,·------.

jExternal Military:

!In-House FFSC:
>'

il

jTri-Care:

!External Civilian:

u,') _________________________
.~

j'Signature of Provider:

i:Sigl~~tur;-~f-Sup;~visor:

L::__._--------

hn

r!.-;;ni,;.cnic

11d\

(b)(6)
(b)(6)

Date of Signature: 1212212009
Date of Signature: 1/6/20i 0

\.mil comp\HlCIHS; form-;,'hillt;\!!Forms.asp\.

----------'

l/7 2011

1

Ciinical Contact Note

~ase Number 60118 Client Name:

(b)(6)

/!C~ntact
Date: 12/10/2009
j;--------------

1!Time Spent: 0
c.---------------- - - Number of Individuals Seen: 0

[_rpe of_founseling Group:

____j_!ype _()f Session:

-----------

.Session Notes:
lf-:Jroup Note/Participation Form
~

i

il

ibate· 9 Dec 09 Client's Name:
IEroup

N~me

, t>eSS/0/i 'fF

6
(bl( J

Cypress Group Leader(si

Manager

(bJ( 6 J

(b)(6)

15

l~bontent of Group Review of "The box" and relapse prevention
l(!·1 =none;

2=rarely; 3=sometimes, 4=often; S=very often)

~~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

i;'i!FFECT THERAPEUTIC CONCERNS
!Ljpbeat xxx Incident of Re-abuse
Guarded Suicidal
!Resentful Increased Risk of Re-abuse
!claim x HGstile, Aggressive Behavior
Frustrated Increased Depression
IR~flective x Increased Stress
jl~appropriate Other_ _ _ _ _ _ _ _ __
/Flat None x
AI_'gry

I

I

Sad
I'A!;lxious

Icbntident
J.,grp•f, 11
Ii R . .,_

~

lil

iOiher
i
~

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/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:

li i

!External Civilian:

ITri-Care:

T

ltsig~atl~~~ of Provider:

(b)(6)

IE3ign;ture of Supervi_s_o-r:-

';------·-----·

. _

·---

---~Date

__
(b)(

6

l

of

Signature:_~~2?12009

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:
!

1

!Type of Session:

_j __

Sesslon Notes:
Date: Sep 30, 09 Client's Name:

l

(b)( 6 )

~v1anager: (b)(6)

I

!Group Name Cypress Group Leader(s):

(b)(G)

I

Sess1on # 12

jcontent of Group Conflict Resolution
1

jc1 ::::none; 2=rare!y, 3=sometimes; 4=often; 5=very often)
!Acceptance Of Responsibility 3
!Personal Disclosures 3
jErnpathy for child and/or others 3
!Knowledge & Understanding of
!Effective Anger ~v1anagement Strategies

!3

Motivation for Change 3
Insight & Se!f Awareness into

Behavior

3

!Respectful attitude 4
!overall Participation 3
i
!AFFECT THERAPEUTIC CONCERNS
!Upbeat xxx Incident of Re-abuse
!Guarded Suicidality
!Resentful Increased R1sk of Re-abuse
!calm x Hostile, ?.ggressive Behavior
jF rustrated Increased Depression
;Reflective Increased Stress
llnappropriate Other

rrFiat ~~one

X

!;Angry

liS ad
IJAnxious
1
,.d en t
!!'C on1L
!.Regretful
:Other
10
t•

!AcJditlonal Comn1ents or Closing Summary:
1

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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:

!:__~-~---------·

I! Signature of Provider:

(b)(6)

!Tri-Care:

!External Civilian:

--·--· 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-

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----------·-

I 7

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finical Contact Note
(b)(6)

ase Number 60118 Client Name:
!Contact Date: 914!2009

1:---··---~-------------·------

---~-

..- - - - -

~Time Spent: 0
11--·-----------·----....
- -..._____________________ ___,!Type

iiNumber of Individuals Seen: 0
lrrype of Counseling Group: - - - - - - - - - - /'_________

-~-----------

of Contact:- - - -

-·---·-------

I

------------~=---==1

iType of Sessio£]_:

iSession Notes:
!:Group Note/Participation Form

1:
!Date
Sep 2, 09 Client's Name:
l;
!:i ~

!Proup Name: Cypress Group Leader(s):

Manager

(b)( 6 l

6
(bJ( )

p

I$ess1on #
I'

~ontent

11

of Group. Physical Cues of Anger

lil=none; 2=rarely; 3=sometimes; 4=often; 5=very often)
I I

J~r,cceptance Of Responsibility 3
:!Personal 01sclosures 3
\lt:mpathy for child and/or others 3
fl::novv'ledge & Understanding of
,ftffect1ve Anger ~vlanagernent Strategies

l

l;t1otivation for Chanoe 3
!rsight & Self ,L'l,wareness into
E}ehavior

l

j,..,

1-i

Ir-~espectful

attitude 4
IC:f";erail Participation 4
il'\FI::ECT THERAPEUTIC CONCERNS

!Upbeat xxx Incident of Re-abuse

IC:~uarded

Suicidality
Resentful Increased Risk of Re-abuse
jC!arrn x Hostile, Aggressive Behavior
1Frustrated Increased Depression
iR'eflective x Increased Stress
lirlappropnate Other
None x
----------

I

/F!at

iApgry

:sacJ
I

!

iA:hxious
i,r-i

..

i

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I~ !-"\It,..
CJ ,~r<
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!Additional
Comments or Closinq
Summar'y.
t
~
!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----;~-------------·---·-.
..
[;ln~Hous~ FF:_c:
jExternal M1htary:

lfsfg~at~~-o:=P~ovid~r:
[~19~2-~-t~-~~~-~f ~~~perv~or:

I

-----------------------------------

!External Civilian:

jTri-·Care:

;

9/4/2009---------------~
(bJ~-----=-_j_~~!:_oTs~~re: -~2!_~200~--==~=j

(b)(s)

----lDate of-Signature:

l 7/20 I I

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Clinical Contact Note
Case Number 60 118 C lient__~~i_!l~-----:~(-1_______________________________________~
6

;f:

I, Contact Date: 8/13/2009

---

--------------------·-··-··-- --------- --······· ------··-·-·------ I

lTime Spent: 0
!Number of Individuals Seen: 0

/Type of Contact:
--------------------

1·-··------·-····----------------·-------·-----------------

lryJ;; of ~ounseling Group:

________j_!_zpe _:?!Session:

---------··------··--··-----1

!Session Notes:
!Group i'-~ote/Partic1pation Form

bate

:'\ug i 2. 09 Client's I'Jame:

(l))(

6

l

I[Group Name: Cypress Group Leader(s)

~.Aanager

(bi( 6 J

6
(b)( )

'
l

'
!SeSSIOn
# 10
~

jContent of Group Masculinity Traps

h

F

1!(1 =none,

2=rarely, 3=sometimes. 4=often, 5-=very often)

~~

~~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
~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

l

!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

t~!_an ~!_<l~-~~--------·--

~
I

-------------====--~-~
.J

__
-------------------------·----------~pia_,gnostic lrnpression r

f;Recommended Referrals:
i'ln-House FFSC:
\External Military:

I

._-----··-----------·-··--------·------------------------·-----·-·---------------------------~

!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)

fc-;;~t;;~To~ te-:81_13_/20_Q~---------------------------........,.----

__________________________ ]

)Type of Contact:

!Time Spent: 0

1---------------------------------------·---J--''-'--------

!.~umber of Individuals Seen: 0

-------,--------------------

·------~~----·····-·JType of Session:

l_!_'t!:)_~_of Counseling Group:

Session Notes:
Group Note/Participation Form
Date. 5 /\ug 09 Client's Name·

(b)( 6 l

!Group Nanx:;: Cypress Group Leader(s)

Case ~Aanager:

(b)(6)

(b)(6)

l
Session# 9
!Content of Group: Recognizing Triggers
l

(1 =none, 2=rareiy, 3=sornetimes: 4=often, S=very often)
;\cceptance Of Responsibility 3+

I Personal Disclosures 4

l Ernpathy

for child andior others 3
Knowledge & Understanding of
Effective Anger Management Strategies

II')

,)

Motivation for Change 3+
Insight & Self !-\\'.>'areness into
18ehaVIOI
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

--·--------------------------

J:!3.~.£~Jmm~!'ded Refe_rr_a_l~s_:- - - - - - - - - - - - - - , - - - - - - - iJn-House FFSC:

11--,

!External Military:

!External Civilian:

~~~~~~~--~-----~~~fSi~na~~~~cios

hll

!Tri-Care:

'"'

_____

j

/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)

!:Group Name Cypress Group Leader(s)

Case Manager

(b)(G)

(b)(6)

iJ

!$ession # 8
li

~~ontent of Group
!Discussion on recognizing & setting boundaries with others using "I statements' as we!!
recognizing 8< accepting their partner's differences

!as
11

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.

h

X

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!lR eg re ttu I
!lC)ther
!i

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

-------------------------1
Mi1ita;y-:-- -----rE-xte·r~-;IC;~~ ---lfri-ca r;-3-

r------------------~----------.
··,
\fJi~gn_?_S.tic Impression ( ·
___ ,_----------------------------------------~

!Plan S!atus

'i

I~Wo~-"£!;~ Referra ~x tern a!
1,1---··'

-------

1\~~gn~~~~=- of Provi_der_

h

''

'

.

6
(bl( )

---------r-:·-----------_______ 1 Da~e of -~lg~~~-~:: 7/31 /20_~9 _________ j

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FAP Clinical Contact Note
(b)(6)

,Case Number 60118 Client Name:

ltcc:_~~-~~~-P~-!~:f!}o/2o~~- ________
i:_2"ime Spent~_?5 __________
!1
i:

I Clinical Provider:

-~-,·--·--

(b)( 6 )
>

-------l

-·······-,-·-~-----------·-·,--·{

J Type of Contact: In Per~o~~----------------J
I

Collateral Contact:
-------

Summary of Contact:
i
1 SM came 1n needing proof that he has attended 8 out of 16 groups of Cypress Provided llwn I
!:V<,ith my card and a note stating that he has been attending
1
fl

1

u---'-----------"'------------"'----------------1

IDate of Signature: 7/10/2009

---'---

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linical Contact Note
(b)(6)

'Case Number 60118 Client Name:

~~-~~-t·;~t D~~~~~~T?_?/2 009 -~=-----~-------------------~==---==---=---~~]
/Type of Contact:

1iTirne Spent: 0

~~~!:~~ber ofl~djvid~~ls$~~:0·--------

/Type of Counseling Group:

-==--

~--

_

j

-~~----·---------==

jType of Session:

~~-~~~-~-~-~J 0 i;~~---·------··--------------------··-·---·--.

···---·-·------·-·-----·-..

,,/Group Note!PartJCipatloh Form
I'

lbate

;!

17 June 09 Client's Name·

(b)(6)

Case manager:

(b)(6)

li

i<
~~jf"Oup Narne ___ Cypress ___________ C3roup l_eader(s).
\l
IPession # 7

I!

l~ontent of Group: Revenge

Jl

ll

2=rarely:
I'(1'l 2=none.
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
:(j)veralf PartiCipation 4

1

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
ryustrated Increased Depression
1
/f·fef!ect1ve x Increased Stress
i ll)appropr~ate Other____
tFiat None
iril!r-gn·
1 1 .. j
I~:~ad

l

t

1

I,.!

.

/P,nXIOUS

-,+

f"ri-I'I("'
· ,-;Oil>lut:.!ltl

IR:egretfur
rif~'·e·'
-...-·,l

l

I

(b)(6)

itional Comments or Closmg Summary

continues to do vvell in group and IS engaged m the process He enthusiastically made
1ndtvidual sessions, picking the topics and working through the issues. He
\'pn=.:sents as genuinely interested in building equity in his relationship.
_ (b)(G)

l!up two absences in

!'

I~

lele

~=0-0-~-~vl-----B-------------- -----

1\r,evlsea

//L.I

b

1

)

~~------

.

.

---------,

IEI<l~l-~!<l!US~-----'---~~--_·_:_i ~-__:=__~_:_·___________:___
' _,_.------------------------~
!biagnostic Impression ' t:: ' ·
I
!R~-co;~~me-~ded-R-efer;;i~~-------------------------------------/1~~-H~~-~e- FFSC: f\ E

!·;-._----

1}~!9~1~-~ur~-~f P-~o-v-id-e-_r--~-

b·!

.j(\

IExtern-~ita;:V_:_
(b)(G)

\ExternaTClvii-i~-----ITri-c~~-:------

---JD~te of Signature: 6i22/2009

-]

----~------·-"--"---~------·-------

'2()

1l

l

!Clinical Contact Note
i

lCase Number 60118 Client Name:

(b)(6)

!contact Date: 6/12/2009
j'------·-----,

lT!m ~-~~~ ~!__1_:_~
lNumber of Individuals Seen: 1
~-

-

------------

!JType of Counseling Group: Other _______________ _jTyp_e -of Session: Individual
--~·
l:s-~ssio-;~-Notes--:
·
1/<.DM completed his second make-up session for Men's DV Group Focus of today's sess1on 1
f~vvas on relationships and "buifding of equity" in a relationship to include long range goals,
li.farnily life, and child development 1\DM continues motivated and interest in personal gro·Nth
,He voices appreciation for vvhat he learns and is looking forward to including what he is
,
.}earning in his relationship. Doing very vvell. Interested, motivated and approprie~te.
·

l

'Plan Status

r

L

7

'](iiI

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