Client Name: Click or tap here to enter text.	Date of Request: Click or tap to enter a date.
Case Monitor: Click or tap here to enter text. Treatment Team Members: Click or tap here to enter text. Legal Guardian: ☐ Yes ☐ No	Agency: Click or tap here to enter text. Level of Care: Choose an item. How long at this level of care? Click or tap here to enter text. Enrolled in APD Services: ☐ Yes ☐ No Enrolled in ID/DD Services: ☐ Yes ☐ No
Please confirm that the following documents have been submitted to the Board
☐ PSRB monthly reports ☐ Prescriber progress notes ☐ Sexual Offending Treatment Notes (☐ N/A)	☐ Last formal Risk Assessment (VRA, START): DATE ☐ Annual Behavioral Health Assessment (BHA) ☐ Annual Individual Services and Supports Plan (ISSP)
Please indicate if any of the following apply
☐ Roommate request (see additional checklist) ☐ Driving request (see additional checklist) ☐ Step down (see additional checklist)
Review of Progress
Yes ☐ No ☐ Is the client currently meeting their conditions of release? Please provide an overview of your client’s engagement in their PSRB program (e.g., treatment, daily routine, community integration, activities of daily living) since their last hearing before the PSRB, focusing on the past six months. Click or tap here to enter text.
Review of Medication Management
Client is presently prescribed psychotropic medication: ☐ Yes ☐ No Last significant psychotropic medication change: Click or tap to enter a date. Please provide an overview of the client’s medication management since their last hearing before the PSRB, including significant medication changes, how medications are overseen, plans for future medication changes, medication training, and any other relevant information related to the client’s medications. Click or tap here to enter text.
Modification Requests Please attach an updated Summary of Proposed Conditional Release Plan
Current Condition (from Current CR Order)	Modified Condition
1	Click or tap here to enter text.	Click or tap here to enter text.
2	Click or tap here to enter text.	Click or tap here to enter text.
3	Click or tap here to enter text.	Click or tap here to enter text.
4	Click or tap here to enter text.	Click or tap here to enter text.
5	Click or tap here to enter text.	Click or tap here to enter text.
Risk Formulation
1.	Clinical Benefits	Click or tap here to enter text.
Associated Risk(s) Select all that apply	☐ Recidivism ☐ Relapse ☐ Psychiatric Decompensation ☐ Relationship Destabilizer ☐ Revocation ☐ Unauthorized Leave ☐ Danger to Others ☐ Other (Click or tap here to enter text.)
Explain Risk(s)	Click or tap here to enter text.
How Risk(s) Will Be Mitigated?	Click or tap here to enter text.
2.	Clinical Benefits	Click or tap here to enter text.
Associated Risk(s): Select all that apply	☐ Recidivism ☐ Relapse ☐ Psychiatric Decompensation ☐ Relationship Destabilizer ☐ Revocation ☐ Unauthorized Leave ☐ Danger to Others ☐ Other (Click or tap here to enter text.)
Explain Risk(s)	Click or tap here to enter text.
How Risk(s) Will Be Mitigated?	Click or tap here to enter text.
3.	Clinical Benefits	Click or tap here to enter text.
Associated Risk(s) Select all that apply	☐ Recidivism ☐ Relapse ☐ Psychiatric Decompensation ☐ Relationship Destabilizer ☐ Revocation ☐ Unauthorized Leave ☐ Danger to Others ☐ Other (Click or tap here to enter text.)
Explain Risk(s)	Click or tap here to enter text.
How Risk(s) Will Be Mitigated?	Click or tap here to enter text.
4.	Clinical Benefits	Click or tap here to enter text.
Associated Risk(s) Select all that apply	☐ Recidivism ☐ Relapse ☐ Psychiatric Decompensation ☐ Relationship Destabilizer ☐ Revocation ☐ Unauthorized Leave ☐ Danger to Others ☐ Other (Click or tap here to enter text.)
Explain Risk(s)	Click or tap here to enter text.
How Risk(s) Will Be Mitigated?	Click or tap here to enter text.
5.	Clinical Benefits	Click or tap here to enter text.
Associated Risk(s) Select all that apply	☐ Recidivism ☐ Relapse ☐ Psychiatric Decompensation ☐ Relationship Destabilizer ☐ Revocation ☐ Unauthorized Leave ☐ Danger to Others ☐ Other (Click or tap here to enter text.)
Explain Risk(s)	Click or tap here to enter text.
How Risk(s) Will Be Mitigated?	Click or tap here to enter text.

Focus on how the modification will promote the client’s ability to more independently manage their qualifying mental disorder.

Focus on the applicable individualized risk factors identified in the client’s past risk assessments.

What monitoring, supervision, or treatment remains in effect to manage the client’s risks?