IDAHO SUPREME COURT 451 WEST STATE STREET P.O. BOX 83720 BOISE, IDAHO 83720-0101 (208)334-2246 APPLICATION FOR APPOINTMENT AS AN EVALUATOR OF PERSONS WHO ARE GUILTY OF DOMESTIC ASSAULT OR DOMESTIC BATTERY UNDER I.C. § 18-918 (IDAHO CRIMINAL RULE 33.3) Part I General Information 1. Qualifications for Appointment: To be deemed eligible for appointment as an evaluator, the applicant must be licensed by the state of Idaho or other state as a physician, psychologist, master social worker, professional counselor, marriage and family therapist, registered nurse, nurse practitioner, or physician’s assistant. In addition, the applicant must have a minimum of one year’s experience following licensure in the assessment or treatment of domestic violence related issues, and submit evidence of twenty (20) hours of specialized education or training in domestic violence matters within the previous two years. 2. Supporting Documentation: An applicant must submit the following to be deemed eligible for appointment as an evaluator by the Supreme Court: A. B. 3. The attached application, including Part V, an affidavit of compliance executed by the applicant attesting that the applicant has fulfilled the requirements for appointment; and A copy of the applicant’s current professional license. To remain on the Supreme Court’s Roster of Evaluators: In order for an evaluator to remain on the Supreme Court’s roster of evaluators, the evaluator must file proof that the evaluator has taken a minimum of sixteen (16) hours of continuing education or training in domestic violence related topics during each preceding two (2) year period, by completing courses approved by the Supreme Court. Proof that the continuing education requirement has been satisfied must be submitted to the Supreme Court by July 1 of each two (2) year period in order to be qualified for the succeeding two-year period. 4. Applications must be typewritten and mailed or delivered to the Idaho Supreme Court, c/o Administrative Director of the Courts, 451 West State Street, P.O. Box 83720-0101, telephone (208)334-2246. 5. Idaho Code § 18-918 and Idaho Criminal Rule (I.C.R.) 33.3 (as revised effective July 1, 2008, are attached for reference. American LegalNet, Inc. www.FormsWorkflow.com IDAHO SUPREME COURT APPLICATION FOR APPOINTMENT AS AN EVALUATOR OF PERSONS WHO ARE GUILTY OF DOMESTIC ASSAULT OR DOMESTIC BATTERY UNDER I.C. § 18-918 (IDAHO CRIMINAL RULE 33.3) Part II APPLICATION FORM (Must Be Typewritten) NAME Organization Mailing Address City Suite County Telephone ( ) State Extension FAX ( ZIP ) E-Mail Address Counties where you are willing to conduct evaluations? The information you furnish above will be used in all correspondence with you and on the roster of evaluators. I herewith apply for appointment by the Supreme Court as a person eligible to conduct evaluations of persons guilty of domestic assault or domestic battery under Idaho Code § 18-918 pursuant to Rule 33.3, Idaho Criminal Rules. In support of this application, I state the following: I am licensed as a by the state of . (Attach a copy of current professional license.) I have [contact] [semester] hours of specialized education or training in domestic violence and have a minimum of one year’s experience after licensure in the assessment or treatment of domestic violence related issues. (Complete Parts III and IV.) Signature Date Please return the completed application with supporting documentation to: Idaho Supreme Court Administrative Director of the Courts 451 West State Street P.O. Box 83720 Boise, Idaho 83720-0101 American LegalNet, Inc. www.FormsWorkflow.com PART III Twenty (20) hours of specialized Education or Training in Domestic Violence within the past two years. Documentation of course attendance must accompany the application. Name: Name of Training or Course: Specify whether semester or contact hours and give the number of hours: Dates attended: Name of sponsoring organization: Detailed explanation of course content and how it relates to domestic violence: Name of Training or Course: Specify whether semester or contact hours and give the number of hours: Dates attended: Name of sponsoring organization: Detailed explanation of course content and how it relates to domestic violence: (Please use additional sheets as needed.) American LegalNet, Inc. www.FormsWorkflow.com PART IV Experience After Licensure in the Assessment or Treatment of Domestic Violence Related Issues In what year was your license first obtained? ______________ Year: Name, Address and Phone Number of Organization or Facility Providing Treatment or Assessment: _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Name of Supervisor or Contact Person at this Facility or Organization: Average hours per month: Detailed Description of Experience: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Year: Name, Address and Phone Number of Organization or Facility Providing Treatment or Assessment: _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Name of Supervisor or Contact Person at this Facility or Organization: Average hours per month: Detailed Description of Experience: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (Please use additional sheets as needed.) American LegalNet, Inc. www.FormsWorkflow.com IDAHO SUPREME COURT APPLICATION FOR APPOINTMENT AS AN EVALUATOR OF PERSONS WHO ARE GUILTY OF DOMESTIC ASSAULT OR DOMESTIC BATTERY UNDER I.C. § 18-918 (IDAHO CRIMINAL RULE 33.3) Part V AFFIDAVIT OF COMPLIANCE State of County of ) ) ss. ) To the Idaho Supreme Court: I, and say that: , being first duly sworn, depose I have submitted this application for appointment as a person eligible to conduct evaluations of persons guilty of domestic assault or battery under Idaho Code § 18-918 pursuant to Rule 33.3, Idaho Criminal Rules. By signing this application, I certify that I have satisfied the requirements therein for making this application. I fully realize that the determination as to whether I am appointed by the Supreme Court depends on the truth and completeness of my answers set forth in this application and the statements attached. To my knowledge, the answers and information which I have supplied in connection with the application are true and complete. I have read and understand the contents of Idaho Code § 18-918(5)(a) and Rule 33.3 of the Idaho Criminal Rules, as revised by the Idaho Supreme Court on July 1, 2007, and I will conduct the evaluation of persons guilty of domestic assault or battery in conformance with these provisions. Date: Applicant's Signature Subscribed and sworn to before me this (SEAL) day of , 200 Notary Public for __________________ Residing at My Commission Expires American LegalNet, Inc. www.FormsWorkflow.com . RULE 33.3. Evaluation of persons guilty of domestic assault or domestic battery. (a) Evaluators. Evaluators of persons who plead guilty or are found guilty of domestic assault or domestic battery under Idaho Code Section 18Ͳ918 shall be approved and shall serve under the following provisions: (1) Qualifications. An evaluator under Idaho Code Section 18Ͳ918(7)(a) shall have the following qualifications: (A) Licensed physician, licensed psychologist, licensed master social worker, licensed social worker if approved prior to July 1, 2008, licensed professional counselor, licensed marriage and family therapist, licensed registered nurse, licensed nurse practitioner or physician's assistant under the laws of the state of Idaho; an evaluator may be licensed in the state of Idaho or any other state; (B) Twenty (20) hours of specialized education or training in domestic violence within the previous two years that meets the criteria set out in subsection (2), as evidenced by an attached certificate of completion or other supporting documentation; (C) One year experience after licensure in assessment or treatment of domestic violence related issues; and (D) Approved by the Domestic Assault and Advisory Board and maintained on a roster by the Administrative Director of the Courts as persons eligible to conduct evaluations of persons guilty of assault or domestic battery. In the event there is no evaluator approved within the judicial district, then the requireͲ ments of (B), (C), and (D) may be waived by the court. (2) Continuing Education of Evaluators. Beginning the next July 1 after an evaluator has been approved by the Domestic Assault and Advisory Board, the evaluator must take at least sixteen (16) hours of specialized training in domestic violence, or related topics in courses approved by the Domestic Assault and Advisory Board, in each and every two (2) year period following the July 1 date. An evaluator must file proof of compliance with this requirement with the Administrative Director of the Courts by July first of the year the continuing education is due. Along with proof of compliance, an evaluator must also send proof of current licensing. (A) The sixteen (16) hours of training required in this section shall be in one or more of the following areas: (a) domestic violence; (b) violence in families; (c) child abuse; (d) anger management; (e) risk factors for future dangerousness; (f)psychiatric causes of violence; or (g) drug and alcohol abuse. However, no more than four (4) of the sixteen (16) required hours may be in the area of drug and alcohol abuse. (B) The sixteen (16) hours of required training in this section shall be acquired by completing a program approved or American LegalNet, Inc. www.FormsWorkflow.com sponsored by one of the following associations: (a) Idaho Psychiatric Association; (b) Idaho Psychologists Association; (c) Idaho Nursing Association; (d) Idaho Association of Social Workers; (e) Idaho Counselors Association; (f) council on Domestic Violence and Victim Assistance; (g) Idaho Coalition Against Sexual Assault and Domestic Violence; or the national equivalent of any of these organizations. (C) Any program that does not meet the criteria set out in both section (a)(2)(A) and section (a)(2)(B) may be submitted to the board for approval either prior to or after completion. (3) Appointment Approval. All evaluators under Idaho Code Section 18Ͳ918(8)(a) must be appointed approved by order of the Domestic Assault and Advisory Board. Any person desiring to be approved as an evaluator shall file an application for approval with the Administrative Director of the Courts indicating the qualifications of the applicant and the dates and content of relevant training courses attended. An evaluator approved by order of the Domestic Assault and Advisory Board may continue in service from one calendar year to the next unless otherwise ordered by the Domestic Assault and Advisory Board. The Administrative Director of the Courts shall maintain a statewide list of approved evaluators by the Domestic Assault and Advisory Board. (b) Advisory Board. (1) Members. There is hereby created a Domestic Assault and Battery Evaluator Advisory Board consisting of six (6) members with experience and training in domestic violence, as follows: (A) A district judge or magistrate judge appointed by the Supreme Court for a term of two years, who shall serve as chair, (B) The Administrative Director of the Courts, or his or her designee, (C) A social worker appointed by the Supreme Court for a term of two years, upon submission of three (3) names by the State Board of Social Work Examiners or appropriate association, (D) A counselor appointed by the Supreme Court for a term of two years, upon submission of three (3) names by the Idaho State Counselors Licensing Board or appropriate association, (E) A psychologist appointed by the Supreme Court for a term of two years, upon submission of three (3) names by the Idaho State Board of Psychologist Examiners or appropriate association, and (F) A psychiatrist appointed by the Supreme Court for a term of two years, upon submission of three (3) names by the State Board of Medicine or appropriate association. (2) Powers of Advisory Board. The Domestic Assault American LegalNet, Inc. www.FormsWorkflow.com and Battery Evaluator Advisory Board shall have the power to make the following recommendations to the Supreme Court: (A) Recommend qualifications and continuing education of evaluators under Rule 33.3(a), (B) Review and recommend for appointment approval or rejection applications of persons to be evaluators under this rule. (C) Recommend the required content and scope of reports of evaluators under this rule, (c) The scope and content of the evaluator's report shall be as follows: (1) Identifying information. (A) Name (B) Address (C) Date of Birth (D) Occupation (E) Current Incident (F) Marital Status (G) Children (H) Military Service (2) Risk Assessment (A) Current and past violent behavior (B) Exposure to violence (C) Threats of homicide/suicide/violence (D) Ideation of homicide/suicide/violence (E) Weapons access (F) Obsessed with or dependent upon victim (Sociopathic Traits) (G) History of rage and impulsivity (H) History of sexual abuse (perpetrator or victim (I) History of child abuse (perpetrator or victim) (J) Access to victim (K) Criminal record (L) Cultural issues (M) History of domestic violence protection orders (N) Prior treatment for aggressive violence (O) Danger of reoffending (3) Substance Abuse (A) Present usage of drugs (B) Prior treatment for drug abuse or addiction (C) Involvement of substance abuse in incident (D) Assessment (4) SelfͲAssessment (A) Description of current incident in person's own words (B) Person's acceptance of responsibility for incident (C) Remorse evidenced by person (D) Person's own view of need for treatment American LegalNet, Inc. www.FormsWorkflow.com (E) Person's willingness to get treatment (5) Test Results (If any Ͳ substance abuse testing, psychological testing , I.Q., etc.) (6) Collateral information (A) Police report (B) Victim interview (C) Prior treatment ͲͲ review of past records (7) Personality/character assessment (8) Behavioral observations/mental status (A) Level of cooperativeness (B) Appearance (C) General present mental status (9) Recommendation (A) A summary formulation that identifies the factors causing and/or contributing to the defendant’s domestic violence that form the basis for the evaluator’s opinion as to the treatment recommendation (B) Further assessment opinions and if needed (C) Treatment recommendations (D) Providers available to treat (E) Cost of treatment (estimate) (F) Cost of alternate treatment (G) Resources available to defendant (d) In the event the evaluator submits an evaluation that is not in compliance with subsection (c) of this rule, the court may return the evaluation with instructions to prepare an evaluation in compliance with the rule at no additional cost to the defendant. In the event an evaluator fails to submit an evaluation in compliance with this rule after such an instruction, the court may forward the evaluation to the Board as a sealed confidential document along with a written request that the evaluator be removed from the roster for failure to comply with the rule. If the Board determines the evaluation fails to meet the requirements of the rule, the evaluator may be removed from the roster. (Adopted effective August 8, 1995; amended August 23, 1996; effective November 1, 1996; amended January 30, 1997, effective February 1, 1997; amended August 3, 1998, effective August 4, 1998; amended March 9, 1999, effective July 1, 1999; amended January 30, 2001, effective July 1, 2001; amended April 22, 2004, effective July 1, 2004; amended May 22, 2006, effective July 1, 2006; amended March 21, 2007, effective July 1, 2007; amended April 4, 2008, effective July 1, 2008) American LegalNet, Inc. www.FormsWorkflow.com