PPCAC PSB-CBT Referral Form
PSB-CBT School Age is designed for children ages 7-12 who display problematic sexual behaviors. PSB-CBT treatment focuses on rules and laws about sexual behavior, privacy and boundary rules, coping skills and impulse control skills, and social skills. Caregivers are involved in treatment and learn to distinguish normal from problematic sexual behaviors in children and youth, appropriate responses to youth's sexual behaviors, ways to prevent problematic sexual behavior, effective responses to other behavioral problems, and effective caregiver/youth communication strategies. This is an open group so referrals can be made at any time and the family is able to start upon completion of an assessment. If you are a professional completing this form, please complete as much as possible. If you are a caregiver completing this form, please provide your child's insurance information. If your child does not have insurance, please select that option below- there is no cost for this treatment. Following the receipt of a referral a clinician will reach out to discuss treatment with the caregiver and schedule an assessment. Please note that this group will be offered only in English for both caregivers and clients.
Referral Source Information
Date of Referral
-
Month
-
Day
Year
Date
Name of person making the referral:
First Name
Last Name
Agency Name (if applicable):
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Relationship to the client being referred:
Is caregiver of client aware of this referral?
Yes
No
Client/Caregiver Information
Name of client being referred:
First Name
Last Name
Child Date of Birth:
-
Month
-
Day
Year
Date
Child's Gender:
Male
Female
Other
Prefer Not to Say
Does child have insurance?
Yes
No
If yes, what type?
Name of caregiver:
First Name
Last Name
Email of Caregiver:
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Caregiver:
Please enter a valid phone number.
Format: (000) 000-0000.
Please select below any custody situations that apply to the client
Child lives with legal guardian
Foster Care/DSS Custody
In the care of a family member or a friend
Any other information that may be helpful for us to know regarding custody:
Reason For Referral:
Concerns about child (check all that apply):
Self-harm
Somatic complaints
Wetting/soiling self
Problematic interactions with caregiver
Problematic interactions with friends
Risk taking behaviors
Moody/Sad
Low self-esteem
Anxiety/fear
Hyperactivity
Anger/aggression
Poor school performance
Sexualized behavior
Sleep problems/Nightmares
Overwhelming grief
In your own words, why are you referring this child for treatment and what behaviors cause you the most concern? Please describe the specific sexual behaviors of concern that the child has demonstrated:
When did the incident last occur?
blanks
How many incidents are known?
blank
With whom did the child have the problematic sexual behaviors? (Please include Name, age of child, relationship to the client).
To your knowledge, is DSS involved?
Yes- DSS is involved related to this incident
No
Unsure
DSS is involved with the family for a different incident
To your knowledge, is law enforcement or Juvenile Justice involved?
Yes
No
Unsure
If yes, please describe the next steps in the investigation and the contact information for investigators involved:
Does the child have any other behavior concerns?
Has child experienced any of the following (check all that apply):
Physical Abuse
Bullying
Community Violence
Sexual Abuse
Neglect
War/Terrorism
Psychological/Emotional
Kidnapping
Witness to intimate partner violence/domestic violence
Other
If "other" please describe:
Has child completed a forensic interview?
Yes
No, but one is scheduled
No, not needed
Unsure
If FI is scheduled, please include the date and the agency that will complete it:
What are the strengths of the child? Anything else you want us to know?
Submit
Should be Empty: