Child Basic Psychosexual Evaluation

Name of Patient:*
Date of Birth*
Date Format: MM slash DD slash YYYY
Name of Person Completing Form:*
Contact Information of Person Completing Form:
Phone*
Email*
Referring Agency:*
Date Written Report is Needed:*
Date Format: MM slash DD slash YYYY
Please list all of the non-sexual legal convictions this child has received in the past*
Please identify the status of any current sexual charges:*
- Pending Adjudication
- Post-Adjudication/Pre-Disposition
- Post Disposition
- There are no legal charges
Please list all of the sexual charges for which this evaluation is being requested. If there are no sexual charges, what are the behaviors of concern that prompted you to request this evaluation?*
Has the child admitted to the sexual offenses?*
- Yes
- No
Why is this child involved with your agency/DFCS? (Please be specific and include dates if applicable)*
Indicate where the child is currently placed and note any specific emotional/behavioral/developmental issues of concern related to psychological functioning:*
Is there any substantiated or suspected abuse of this child?*
What school does this child attend, what grade is he/she in, and are there any academic difficulties?*
Please list any specific medical problems:*
Please list any previous or current mental health providers and list all psychiatric medications child is presently taking:*
Please note that a police report (if available) and any documentation related to the sexual charge(s) are required for this evaluation to be completed.
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Child Basic Psychosexual Evaluation

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