Program Exception Request Form

Request Section
Inmate Information
Last Name, First Name: Enter Name
IDOC #: IDOC #
Date: Select Date
Requestor Information
Requestor Name: Enter Name.
Position: Enter Position.
Phone Number: Enter Number.
Ext. Enter Ext.
Facility: Choose Facility.
Program Exception Request - Must be reviewed by program manager or designee
Summary: Include the reason for the exception, barriers to treatment completion, and case plan history. Sex offender requests must include current crime criminal history, juvenile or
adult, year, age of victim, age of inmate, sentence, and past treatment.
Enter Text.
Interventions: Include what responsive treatment interventions have been used.
Enter Text.
Review Section
Program Manager Review
Program manager: Enter Name.
Date: Select Date.
☐ Approved
☐ Denied
Comments: Enter Comments.
Mental Health Review (if necessary)
Clinician: Enter Name.
Date: Select Date.
☐ Approved
☐ Denied
Comments: Enter comments.
Medical Review (if necessary)
Medical professional: Enter Name.
Date: Select date.
☐ Approved
☐ Denied
Comments: Enter Comments.
Director of Programs Review
Program director: Enter Name.
Date: Select date.
☐ Approved
☐ Denied
Comments: Enter comments.
Parole Coordinator Review (If Necessary)
Parole coordinator: Enter Name.
Date: Select Date.
☐ Approved
☐ Denied
Comments: Enter Comments.
Clinical Supervisor
Health Services Director
Chief Psychologist
☐ Approved
☐ Denied
☐ Approved
☐ Denied
☐ Approved
☐ Denied
Return completed form to the director of programs.
IDAHO DEPARTMENT OF CORRECTION
Program Exception Request (PER) Form
607.26.01.014
(Last revised on 05/18/2017)Page 1 of 1