IDesILaytagsG31 20226092001Millie BrombacherDSHS 20_226.itpb4jH  G<:T, &,28>DJPV\bhntz6`Submit 6 ⴯66$H4*.0325904301345050035140800190180187jH"@X  2b @@@@@@ @@@@@fv,>^s, >UGrsG ,UG|b2fv0T)uG,0b2T)fv5 uG yaGT)   uG GvGT)LvGT)0oGB@@@  @@X  GsrG @@@N680!0!1&@XXjdVXXd'd?d 0 <wfdiughp{vtqe ndsourj l>mOk1 ClientName JRA Number BirthDateWitnessPrintName WitnessTitleWitnessSignatureWitnessSignatureDateMedicalRecordsNoSCCnoDOCnoFBIno StateIDNo ReadAbove ExplainedToMeClientRefusesToSignClientSignatureClientSignatureDateClientPrintName DSHSNumber4 x  (  " (]]]]]Y]]]]  porpsilaZ porpsila` porpsilal porpsilarDatavihgutsrqponmlkjfed<EArialTimes New RomanTimN"N<Z3Submit :f 20226092001UGrsGH 1UG\^fv`T)Millie Brombacher`^DSHST)fveuG 20_226.itp144lXXjdVXXd'd?d6Tr6~this, SignatureVersion Data Vers$ Blue Keys*Graphics0Headerx6 FieldList< Form Infof LayoutPropsx DesPathInfo8~`b0' // @@X   @@@@@@ @@@@@(T8T(T !D0`/_T0 !`/|5} ,T"} `T`/p@~ } ~T}|"T`/'T$`/TLA"`/T"@/\A}H5A/ 5I"/ A"@@@  @@X   @@@  @@X   @@@   @@X   2HNT HNT(;HT!"@.$`0" L>SEXUALLY VIOLENT PREDATOR ASSESSMENT NOTIFICATION OF LACK OF CONFIDENTIALITY  $  % @@  dP  CLIENT'S NAME B=@`$`@  ePp$P  JRA NUMBER B4@@  fP  DATE OF BIRTH B=/ / %DSHS 20-226 (REV. 09/2001) TRANSLATEDp{,.@-p  j,-q WITNESS' NAME (PLEASE PRINT) ",.$`@-p  k, -q$P TITLE "*p,p@+0 l*+1` WITNESS' SIGNATURE "X*pp,$`@+0  m*+1$P DATE ")@*p$`8)*@ WITNESS   p-  @P  nQ p MEDICAL RECORDS NUMBER "s @P  o Q  SCC NUMBER "6 @P  pQ  DOC NUMBER "7 `@P  qQP  FBI NUMBER "2` $`@ P  rpQ$P STATE ID NUMBER "I !0 RThe purpose of this interview/assessment is to conduct an evaluation of you as a sexually violent predator. You may be asked oral or written questions. None of your answers, nor any other statements you make are confidential. ANY AND ALL STATEMENTS YOU MAKE MAY BE USED AS EVIDENCE AGAINST YOU IN A FUTURE CRIMINAL OR CIVIL PROCEEDING, INCLUDING A SEXUALLY VIOLENT PREDATOR PROCEEDING. A SEXUALLY VIOLENT PREDATOR CIVIL COMMITMENT PROCEEDING IS A CIVIL, NOT CRIMINAL, PROCESS.      4" 4"   4",Arial (>QThe purpose of this interview/assessment is to conduct an evaluation of you as a (>Vsexually violent predator. You may be asked oral or written questions. None of your (>>answers, nor any other statements you make are confidential. ( ANY AND ALL (>=STATEMENTS YOU MAKE MAY BE USED AS EVIDENCE AGAINST YOU IN A (>BFUTURE CRIMINAL OR CIVIL PROCEEDING, INCLUDING A SEXUALLY VIOLENT (>8PREDATOR PROCEEDING. A SEXUALLY VIOLENT PREDATOR CIVIL (>7COMMITMENT PROCEEDING IS A CIVIL, NOT CRIMINAL, PROCESS(.PP!0 3RIf your answer to a particular question might incriminate you in a future criminal proceeding, you have the right to refuse to answer that question. IF YOU REFUSE TO ANSWER ANY PARTICULAR QUESTION, YOUR REFUSAL MAY BE USED AS EVIDENCE AGAINST YOU IN A SEXUALLY VIOLENT PREDATOR CIVIL COMMITMENT PROCEEDING.   2 3  &&4 &4 4" 4,Arial (1>SIf your answer to a particular question might incriminate you in a future criminal (A>Cproceeding, you have the right to refuse to answer that question. (AIF YOU REFUSE TO (Q>:EVIDENCE AGAINST YOU IN A SEXUALLY VIOLENT PREDATOR CIVIL (q>COMMITMENT PROCEEDING(q.!0  *Whether you choose to remain silent, or answer any particular question, or make any particular statement, is solely your decision. Another person cannot make that decision for you. You have the right to consult with an attorney to assist you in making that decision.   w4 4w 4 w4,Arial (>TWhether you choose to remain silent, or answer any particular question, or make any (>Yparticular statement, is solely your decision. Another person cannot make that decision (>Vfor you. You have the right to consult with an attorney to assist you in making that (> decision. *I have:     p& p@@   s p0 $*Read all of the above statements; OR  $   " @ @@   tP 0 $*The statements have been read to me.  $   " #p$@@   u#$0 *Client refuses to sign.     "~ ')P @ ' g' ' CLIENT'S SIGNATURE "U' )P@'  h' 0' DATE "')P$`@'  i'  '$P CLIENT'S NAME (PLEASE PRINT) "~%'$`8&0&` CLIENT   p$ @`@  vPP  DSHS NUMBER ";`@`@BCLIENT'S NAME (PLEASE PRINT) {%'$`8&0&` CLIENT   #  Ǿ$%IGT' )P@ '  h' 0' *DATE  Ǿ$%IG')P$`@'  i'  '$P *CLIENT'S NAME (PLEASE PRINT)  Ǿ$%IG}%'$`8&0&` F*CLIENT    F t$  HH OLF @2O :i+00#C:\4"&My DocumentsMYDOCU~1 E%6"1f'=Work to doWORKTO~12* 20-226.itpT-S C:\My Documents\Work to do\20-226.ITP(..\..\My Documents\Work to do\20-226.ITPC:\My Documents\Work to doaxS: h~$/ ?HH մ>?8 =>HH մ=>8 <=HH մ<=8 ;<HH մ;<8 :;HH մ:;8 9:HH մ9:8 89HH մ898 78HH մ788 67HH մ678 56HH մ568 45HH մ458 34HH մ348 23HH մ238 12HH մ12H 01HH մ01H /0HH մ/0H ./HH մ./H -.HH մ-.H ,-HH մ,-H +,HH մ+,H *+HH մ*+H )*HH մ)*H ()HH մ()H '(HH մ'(H &'HH մ&'H %&HH մ%&H $%HH մ$%H #$HH մ#$H "#HH մ"#H !"HH մ!"H !HH մ !H  HH մ H HH մH HH մH HH մ< HH մ< HH մ< HH մ< HH մ< HH մ< HH մ< HH մ< HH մ< HH մ< HH մ< HH մ2 HH մ2 HH մ2 HH մ2 HH մ 2 HH մ 2 HH մ & HH մ & HH մ &  HH մ & HH մ& HH մ& HH մ& HH մ& HH մ& HH մ& HH մ& HH մ  HH մ HH մ HH մj HH մj HH մj HH մj