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 the current sexual charges:*
- Pending Adjudication
- Post-Adjudication/Pre-Disposition
- Post Disposition
Please list all of the sexual charges for which this evaluation is being requested*
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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Accepted file types: pdf, doc, docx.