Today Y-M-D
Name of person entering the form
* must provide value
Was this child screened out?
Yes
No
Yes
No
Why is the referral on hold?
Office use only
Contact related to referral
Is this a referral for something other than PSB?
Yes
No
Yes
No
Office use only: NOT an open referral (e.g. CARE Screener only). You can come back and uncheck the box later if the referral opens up.
IMPORTANT: if the caregiver is not the child's biological parent, please upload documentation here e.g. adoption paperwork, guardianship legal documents
First Name
* must provide value
Last Name
* must provide value
Date of Birth
* must provide value
Today Y-M-D
Pre-school
School-age
No program
Gender
* must provide value
Male
Female
Other
What pronouns does this child use?
He/him
She/her
They/them
Prefer to self-describe:
Please specify other pronouns
Does the child speak English?
* must provide value
Yes
No
Is there an expected change of placement within three months?
* must provide value
Yes
No
Do not know
N/A
Is treatment participation court mandated?
* must provide value
Yes
No
Do not know
N/A
Date Referred
* must provide value
Today Y-M-D
View equation Referral Source 1
* must provide value
DHS Parent/Self Other Family Member Therapist/Counselor Healthcare Provider School/Teacher CARE Center CASA Court St. Anthony Hospital Bethesda Genesis Probation Officer Other
Please share how you learned about the program
* must provide value
Website DHS Other Family Member Therapist/Counselor Healthcare Provider School/Teacher CARE Center CASA Court St. Anthony Hospital Bethesda Genesis Probation Officer Other
Contact Referral Source 1: First Name
* must provide value
Contact Referral Source 1: Last Name
* must provide value
Referral Source 1 email address
Contact Referral Source 1: Work Phone Number
Contact Referral Source 1: Cell Phone Number
Are you in involved with a Child Advocacy Center or free-standing multi-disciplinary team?
Yes
No
Referral Source 2
* must provide value
DHS Parent/Self Other Family Member Therapist/Counselor Healthcare Provider School/Teacher CARE Center CASA Court St. Anthony Hospital Bethesda Genesis Probation Officer Other
Contact Referral Source 2: First Name
Contact Referral Source 2: Last Name
Referral Source 2 email address
Contact Referral Source 2: Work Phone Number
Contact Referral Source 2: Cell Phone Number
Report made to DHS/Indian Child Welfare (ICW)?
* must provide value
Yes
No
DHS Involved?
* must provide value
Yes No Unknown
Child is in DHS custody and/or DHS is the legal guardian
Yes
No
Parental Rights of Mother
Parental rights intact/Primary or Joint Custody Regular visitation Working towards treatment plan Court pursuing termination/Termination likely Rights terminated Rights relinquished, Parent deceased Parent unknown Parent not involved in child's life
Parental Rights of Father
Parental rights intact/Primary or Joint Custody Regular visitation Working towards treatment plan Court pursuing termination/Termination likely Rights terminated Rights relinquished, Parent deceased Parent unknown Parent not involved in child's life
Is there a plan for reunification with parents?
Yes
No
Do not know
N/A
Child in Therapeutic Foster Care
Yes
No
Is there a permanency plan for the child?
Yes
No
N/A
What is the permanency plan?
Reunification Adoption/Guardianship (Kinship) Adoption/Guardianship (Foster) Other
Elaborate on placement plan for child
Caseworker Work Phone Number
* must provide value
Caseworker Cell Phone Number
JB Involved?
* must provide value
Yes No Do not know
OJA Involved?
* must provide value
Yes No Do not know
Child referred by OJA/JB?
Yes No Do not know
Yes No Do not know
Does child have a public attorney?
Yes No Do not know N/A
Probation Officer First Name
Probation Officer Last Name
Probation Officer Work Phone Number
Probation Officer Cell Phone Number
Probation Officer Email Address
Is the primary caregiver the referral source listed above?
* must provide value
Yes
No
Has caregiver been notified of referral?
* must provide value
Yes
No
Please notify the caregiver immediately.
First Name
* must provide value
Last Name
* must provide value
Gender
* must provide value
Male
Female
Other
What pronouns does the primary caregiver use?
He/him
She/her
They/them
Prefer to self-describe:
Please specify other pronouns
Does the caregiver speak English?
* must provide value
Yes
No
Street address (and suite/apt # if applicable)
* must provide value
State
* must provide value
Zipcode
* must provide value
5-digit zipcode
Relationship to Child
* must provide value
mother/father stepparent foster parent kinship foster care adoptive parent grandparent therapist CASA worker staff at group home other family member other relationship
Other relationship to child
Does child have secondary caregiver?
* must provide value
Yes
No
Is the secondary caregiver the referral source listed above?
* must provide value
Yes
No
First Name
* must provide value
Last Name
* must provide value
Gender
* must provide value
Male
Female
Other
What pronouns does the secondary caregiver use?
He/him
She/her
They/them
Prefer to self-describe:
Please specify other pronouns
Is the secondary caregiver's address the same as the primary caregiver's?
* must provide value
Yes
No
Street address (and suite/apt # if applicable)
* must provide value
State
* must provide value
Zipcode
* must provide value
5-digit zipcode
Relationship to Child
* must provide value
mother/father stepparent foster parent kinship foster care adoptive parent grandparent therapist CASA worker staff at group home other family member other relationship
Other relationship to child
Number of other professionals involved
0 1 2 3 4
First name of professional #1
Last name of professional #1
Child's Attorney Caregiver's Attorney Judge District Attorney Therapist In-Home Therapist Psychiatrist Teacher Police Officer OJA Officer Other
Address of professional #1
street number, city, state, zipcode
Phone number of professional #1
Email address of professional #1
Release form obtained from professional #1?
Yes No N/A
First name of professional #2
Last name of professional #2
Child's Attorney Caregiver's Attorney Judge District Attorney Therapist In-Home Therapist Psychiatrist Teacher Police Officer OJA Officer Other
Address of professional #2
street number, city, state, zipcode
Phone number of professional #2
Email address of professional #2
Release form obtained from professional #2?
Yes No N/A
First name of professional #3
Last name of professional #3
Child's Attorney Caregiver's Attorney Judge District Attorney Therapist In-Home Therapist Psychiatrist Teacher Police Officer OJA Officer Other
Address of professional #3
street number, city, state, zipcode
Phone number of professional #3
Email address of professional #3
Release form obtained from professional #3?
Yes No N/A
First name of professional #4
Last name of professional #4
Child's Attorney Caregiver's Attorney Judge District Attorney Therapist In-Home Therapist Psychiatrist Teacher Police Officer OJA Officer Other
Address of professional #4
street number, city, state, zipcode
Phone number of professional #4
Email address of professional #4
Release form obtained from professional #4?
Yes No N/A
Sexual Behavior Problems: information from referral source
Sexual Behavior Problems: information from caregiver
When did the last incident occur?
Today Y-M-D
How many incidents are known?
Did child initiate sexual contact?
Yes No Unknown
Did child use coercion/force?
Yes No Unknown
Other symptoms of concern (e.g., anxiety, depression, behavior problems, delays) or important information?
Does the child have additional behavioral concerns?
Has the child had a victimization experience?
Yes
No
Suspected
How as the child been victimized?
check all that apply
Please specify other victimization
Details of victimization(s)
Has child completed a forensic interview?
Yes
No, but will complete
No, not needed
Unsure
Date forensic interview is scheduled or was completed
Today Y-M-D
Where was (or will) the forensic interview completed?
Concerns about child (check all that apply)
* must provide value
check all that apply
Please list concerning risk taking behaviors
Please list other concerns
Number of children involved
0 1 2 3
First name of first child involved
Last name of first child involved
Age of first child involved
Gender of first child involved
Male Female Other Unknown
Relationship of first child involved
Sibling Cousin Neighbor Schoolmate Half-sibling Peer
Familiarity with first child involved
Extensive contact Periodic contact Limited contact First contact
Does first child involved need services related to the incident?
Yes No Possibly Unknown
First name of second child involved
Last name of second child involved
Age of second child involved
Gender of second child involved
Male Female Other Unknown
Relationship of second child involved
Sibling Cousin Neighbor Schoolmate Half-sibling Peer
Familiarity with second child involved
Extensive contact Periodic contact Limited contact First contact
Does second child involved need services related to the incident?
Yes No Possibly Unknown
First name of third child involved
Last name of third child involved
Age of third child involved
Gender of third child involved
Male Female Other Unknown
Relationship of third child involved
Sibling Cousin Neighbor Schoolmate Half-sibling Peer
Does third child involved need services related to the incident?
Yes No Possibly Unknown
If other children noted are relatives and need services so that family therapy, reunification, and other
Archive this case/family?
Yes
No
Submit
Save & Return Later