PSB Program Referral Form
Ages 7-12
Caregiver involvement required.
This referral is not a guarantee of acceptance into group or treatment. Each youth will be assessed by a licensed clinician to ensure criteria is met.
Youth Name
*
First Name
Last Name
Youth Date of Birth
*
-
Month
-
Day
Year
Date
Youth Age
*
Youth Ethnicity
*
Youth Gender
*
Please Select
Male
Female
Other
Date of Referral
*
-
Month
-
Day
Year
Date
County
*
Zip Code
*
REFERRAL SOURCE
Contact Person
*
First Name
Last Name
Agency/Relation
Juvenile Services
Child Welfare
Judge/Court Order
Mental Health Provider
School
Medical Provider
Law Enforcement
Multidisciplinary Team Member
Other
Contact Email
*
example@example.com
Office Phone Number
*
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Caregiver Notified of Referral (Please notify caregiver immediately if you have not)
Yes
No
CHILDREN'S DIVISION INVOLVEMENT
Is Children's Division involved?
*
Yes - Case Open
Yes - Case Closed
No
Other
If yes, does Children's Division have custody of youth?
Please Select
Yes
No
Primary County
Foster home?
Please Select
Yes
No
Types of abuse/neglect
Sexual abuse
Physical abuse
Neglect
Domestic violence
In need of treatment/supervision
Other
Caseworker Name
First Name
Last Name
Caseworker Primary Phone Number
Please enter a valid phone number.
Caseworker Email
example@example.com
Permanency Plan
Any other information regarding Children's Division involvement/permanency plan
CAREGIVER INFORMATION
Primary Caregiver
*
First Name
Last Name
Gender
*
Please Select
Male
Female
Other
Relationship to Youth
*
Caregiver Date of Birth
*
-
Month
-
Day
Year
Date
Caregiver Ethnicity
*
Caregiver Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caregiver Primary Phone
*
Please enter a valid phone number.
Alernate Primary Phone
*
Please enter a valid phone number.
Caregiver Email
*
example@example.com
Best Way to Contact
*
Please Select
Call
Text
Email
Biological Parent Information
If different from primary caregiver
Biological Mother Name
First Name
Last Name
Biological Mother Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Biological Mother Email
example@example.com
Biological Mother Phone Number
Please enter a valid phone number.
Biological Father Name
First Name
Last Name
Biological Father Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Biological Father Email
example@example.com
Biological Father Phone Number
Please enter a valid phone number.
Reason youth does not live with biological parent
REASON FOR REFERRAL
How many incidents are known?
*
Age of youth at time of PSB
*
When did the last incident occur?
*
Total number of victims
*
Has the youth ever initiated sexual contact?
*
Please Select
Yes
No
Was coercion used?
*
Please Select
Yes
No
With whom did the youth have the problematic sexual behavior? Please list name, age, relationship, and services needed related to the incident.
*
Does the youth exhibit other symptoms/behaviors of concern?
*
Other important information about this youth
*
Other Professionals Involved
Therapist Name
First Name
Last Name
Therapist Phone Number
Please enter a valid phone number.
Psychiatrist Name
First Name
Last Name
Psychiatrist Phone Number
Please enter a valid phone number.
Counselor Name
First Name
Last Name
Counselor Phone Number
Please enter a valid phone number.
Counselor Name
First Name
Last Name
Other professionals (Name and contact information)
Submit
Should be Empty: