Client Name:	Date of Request: Click or tap to enter a date.
Case Monitor: Click or tap here to enter text. 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.	Legal Guardian: ☐ Yes ☐ No Enrolled in APD Services: ☐ Yes ☐ No Enrolled in ID/DD Services: ☐ Yes ☐ No Treatment Team Members: Click or tap here to enter text.
☐ PSRB monthly reports up to date ☐ PSRB prescriber notes up to date ☐ CR Order provides ED discretion to approve modification
Modification Request
Select One
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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 since their last hearing before the PSRB (e.g., treatment, daily routine, community integration, activities of daily living), focusing on the request type: Select One.
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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.
Risk Formulation
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?