Normal Topic Maintenance Poly Questions; Interesting. (Read 2280 times)
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Maintenance Poly Questions; Interesting.
Jun 25th, 2004 at 6:55am
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CVSA Comparison Study



Name: ___________________________________________________ Date:____________

Your last examination was on_____________________ . Since then have you: (circle "Y" for yes, "N" for no, explain where needed)

Y N 1. Had sexual relations will, anyone? (list first name and age)

(a)_________________________________ (b)_________________________________
Y N 2. List the locations besides your horde where you've engaged in sexual activity.

(a)_________________________________ (b)_________________________________
Y N 3. Rented any X-rated movies, looked at pornographic magazines, been to any houses of prostitution or adult book/sex type stores?

Y N 4. Had any sexual contact with animals?

Y N 5. Had any kind of contact with any of your victims (direct, phone, letters or messages of any kind)?

Y N 6. Have you masturbated? (When, where, most number of times in 1 day)

(a)_________________________________ (b)_________________________________ (c)_________________________________
Y N 7. Do you ever think or fantasize about any of your victims while masturbating?

Y N 8. Had any kind of contact with children or persons under 18 that would violate your probation or conditions of treatment?

Y N 9. Does your group treatment program know of all persons you've had sexual contact with since your last examination?

Y N 10. Engaged in any sexual activity with the person(s) listed above that the groupwould consider sexually improper? (Use of physical force, fantasies, trickery, etc.)

Y N 11. Lied or misrepresented any important information in treatment?

Y N 12. Done anything at all of an improper sexual nature that the group would disapprove of? (Besides what's already on this form) Explain fully.

________________________________________________________ ________________________________________________________ ________________________________________________________
Y N 13. Left the state without permission? Explain if "YES" answers.

________________________________________________________ ________________________________________________________ ________________________________________________________
Y N 14. Been with anyone when they committed any criminal act of any kind?

Y N 15. Stolen anything at all? (Shoplifting, from work, etc.)

Y N 16. Had any alcoholic beverage to drink? (When-Where-How much)

Y N 17. Seen illegal drugs being used or in the possession of anyone else?

Y N 18. Been present or took part in any kind of drug transaction?

Y N 19. Used any illegal drug yourself?

Y N 20. Used anyone else's prescription medication?

Y N 21. Been contacted by the police for anything?

Y N 22. Committed any minor traffic violations you weren't caught for?

Y N 23. Committed any kind of "general law" type violation for which you could have received a ticket or been arrested? (Bad checks, assault, criminal mischief, fish and game, weapons violations, littering, etc.)

Y N 24. Done anything else we should talk about that could violate probation?

I have told the absolute truth on this treatment questionnaire form:

Signature: _________________________________________________________________
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Maintenance Poly Questions; Interesting.

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