Supervision Officer Referral Form
Ronald Russell Polygraph Service
Clinical Polygraph Referral Form / Confidential
Referral Date:
Supervision Officer:
Offender's Name:
Instant Offense:
Time frame for exam:
Select only one examination type:
Instant Offense:
Sexual History:
Monitoring:
Maintenance:
Specific Issue:
Other:
Comments / Special Concerns:
Sexual history exam requires completed packet. Instant Offense exam requires summary sent to examiner prior to test.
Right click links below to save as:
> Click < Houston Office Map / Directions .doc format
Download Sexual History Questionnaire .doc format
