PSB-CBT Referral Form – Child Advocacy Center of Aiken County

Today’s Date: *

Child’s Name: *

First

Last

Child’s Age: *

Child’s DOB: *

Child’s Gender: *

Child’s Ethnicity: *

Child’s Social Security Number: *

Contact Person: *

Agency/Organization: *

If caregiver, type "N/A"

Primary Phone: *

Email: *

Has a report been made to DHS/ICW? *

Yes
No
I’m not sure.

Has there been DHS/ICW involvement? *

Yes- In the past.
Yes- Currently
No
I’m not sure.

If yes to Question 13, please provide the agency contact name and phone. *

Is the child in therapeutic foster care? *

Yes
No
I’m not sure.

Is law enforcement/JB/OJA involved? *

Yes
No
I’m not sure.

If yes to Question 16, please provide the agency contact name and phone.

Has the caregiver been notified of this referral? *

Yes
No- Please notify the caregiver immediately.
I am the caregivier.

Has the biological mother's parental right been terminated? *

Yes
No
I’m not sure.
N/A

Has the biological father's parental right been terminated? *

Yes
No
I’m not sure.
N/A

Is there a plan for reunification with parents? *

Yes
No
I’m not sure.
N/A

Is there a permanency plan for the child? *

Yes
No
I’m not sure.
N/A

Primary Caregiver Name: *

Primary Caregiver DOB: *

Primary Caregiver Ethnicity: *

Relationship to Child: *

Primary Caregiver Home Address: *

Primary Caregiver Email: *

Phone: *

Best time to call? *

Morning
Afternoon
Evening
Other

Additional Primary Caregiver Information

Please include: Full Name, DOB, Ethnicity, Relationship to Child, Address, and Primary Phone

Legal Guardian: *

Caregiver
DSS
Other

Biological Mother Name: *

First

Last

Biological Mother DOB: *

Biological Mother Ethnicity: *

Biological Mother Home Address: *

Biological Mother Email:

Biological Primary Phone:

Biological Father Name: *

First

Last

Biological Father DOB: *

Date

Time

Biological Father Ethnicity: *

Biological Father Home Address: *

Biological Father Email:

Biological Father Primary Phone:

Is the referral source a caregiver? *

What are the specific sexual behaviors of concern that the child has demonstrated? *

When did the last incident occur? *

How many incidents are known? *

Has the child ever initiated sexual contact? *

Yes
No
I’m not sure.

Was coercion used?

Yes
No
I’m not sure.

Does the child have any additional behavioral concerns? *

Has the child had a victimization experience? *

Yes
No
I’m not sure.

If yes, please check all that apply: *

Physical Abuse
Sexual Abuse
Neglect
Psychological/Emotional Abuse
Bullying
Hate Crime
School Violence
Kidnapping
Community Violence
Accident
War/Terrorism
Witnessing DV or a Violent Crime
Other

behavioral Please the

Please provide any details based on your above selections (if any)

Has the child completed a forensic interview? *

Yes
No
No, but one is scheduled.
I’m not sure.

hen is the forensic interview scheduled or was completed? *

Where is the forensic interview scheduled or was completed? *

Concerns about the child (check all that apply): *

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 self
Sexualized behavior
Problematic interactions with friends
Problematic interactions with caregivers
Risk taking behavior
None of the above. Child seems to be functioning well.

Please provide any details based on your above selections (if any)

Please provide any other important information below (if any)