PSB-CBT Referral Form

PSB-CBT REFERRAL SHEET
Contact Person: Tana Blackburn 336-818-0733 ext. 201

Ages 7-12 Caregiver involvement required Each youth will be assessed by a licensed clinician to ensure criteria is met.
Date*

MonthDayYear
Date
Alpha
Name*

Childs first nameChilds last name
County*
DOB*
Age*
Ethnicity*
Gender*
Street*
City*
State*
Zip Code*
Home phone*
Work/Cell phone*
Legal Guardian*
Relationship*
Referral Source Contact Person:
First*
Last*
Agency/Relation
DJJ
DSS/CPS
Court
Attorney
Primary Care Provider
CAC
Mental Health Provider
School
Law Enforcement
Other
Agency Contact Email
example@example.com
Office Phone Number
Caregiver Notified of Referral (Please notify caregiver before referring) DSS/CPS Involvement: Yes-Open
Yes
No
DSS/CPS Involvement
Yes-Open
Yes-Closed
No
Other
If yes does DSSCPS have custody
Primary County
Foster Home
DJJ Involvement
Yes-Open
Yes-Closed
No
Other
Types of abuse/neglect
Sexual Abuse
Physical Abuse
Neglect
Domestic Violence
In need of treatment/supervision
Other
Caseworker Name
Phone/Email
DJJ Name
Phone/Email
Is biological mother's parental rights terminated?
Yes
No
Don't Know
Is biological father's patrental rights terminated?
Yes
No
Do not know
Is there a plan for reunification with parents?
Yes
No
Do not know
Is there a plan for permanency plan for the child?
Yes
No
Do not know
If necessary then please use the space below to elaborate on the permanency plan
Primary caregivers names
Dates of birth

MonthDayYear
Date
Ethnicity
Relationship to child
Biological Parent Information-If different from caregiver above:
Parents name
Date of birth

MonthDayYear
Date
Ethnicity
Address
Home phone
Cell phone
Work phone
Biological Parent Information-If different from caregiver above:
Parents name
Date of birth

MonthDayYear
Date
Ethnicity
Address
Home phone
Cell phone
Work phone
Therapist
Phone
Psychiatrist
Phone
Systems of care
Phone
Other
Phone
Reason For Referral-Referral Source Report
Is Referral Source a caregiver?
Yes
No
What are the specific sexual behaviors or concerns that the child has demonstrated
When did the last incident occur
How many incidents are known
With whom did the child have the problematic sexual behaviors?
Name
Age
Relationship
Need services related to incident?
Name
Age
Relationship
Need services related to incident
Name
Age
Relationship
Need Services related to incident
Name
Age
Relationship
Need services related to incident
Has the child ever initiated sexual contact?
Yes
No
Was coercion used?
Yes
No
Does the child have additional behavioral concerns
If other children noted are relatives and need services so that family therapy reunification and other similar factors Need to be considered then please provide details
Has child had a victimization experience?
Yes
No
Suspected
Complete below (check all that apply)
Physical Abuse
Sexual abuse
Neglect
Psychological/Emotional abuse
Bullying
Hate Crimes
School Violence
Kidnapping
Accident
War/Terrorism
Community Violence
Witness intimate partner violence/Domestic Violence
Other
Please list other
Details
Has child completed a forensic interview
Date forensic interview is scheduled or completed

MonthDayYear
Date
Concerns about child (check all that apply):
No identifiable problems: child appears to be functioning well
Not minding
Moody/Sad
Hyperactivity
Sleep problems/Nightmares
Self-harm
Low self-esteem
Anger/Aggression
Bothersome memories
Somatic complaints
Anxiety/Fear
Poor School Performance
Overwhelming grief
Wetting/Soiling
Sexualized behavior
Problematic interactions with friends
Problematic interactions with caregivers
Risk taking behaviors
Other
Explain other
Risk taking behaviors
Details
Strengths of the child
**Fax completed forms to (336-571-1012), ATTN: PSB-CBT Senior Leader

1260 College Ave #1, Wilkesboro, NC 28697 336-818-0733 336-818-0734 (Fax) jodi.province@gmail.com
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PSB-CBT REFERRAL SHEET