Pathfinder

Date field

Referred By

Referral Phone Number

County of Referral

Client

Age

Date of Birth

Has a psychosexual evaluation been completed?

Yes

Don't Know

Legal Guardian

Caretaker

Address - Street Number, Street Name, City, State, Zip Code

County

Primary Phone Number

Okay to Leave a Message?

Yes

Owner?

Secondary Phone Number

Okay to Leave a Message?

Yes

Owner?

Email Address

If none, type N/A

Owner

Names & Ages of Siblings, Other Children, or Individuals Living in Home

If none, type N/A

Last four digits of SSN for female caretaker

If unknown or N/A, type 0000. For information purposes only.

Name, age, and relationship of victim/s

If unknown, type N/A

Is there a safety plan in place?

If so, briefly describe safety plan

Criminal Justice Involved?

Yes

Don't Know

Reported to Authorities?

Yes

Don't Know

If Yes, Whom?

If unknown, type N/A

Charges Brought?

Yes

Don't Know

If So, What?

If unknown, type N/A

County of Jurisdiction

If not on probation, type N/A

Probation Officer

If not on probation, type N/A

Phone Number

If not on probation, type N/A

Does referred child/adolescent have any physical or developmental disabilities?

If so, briefly explain. If no, type N/A

Is referred child/adolescent taking any prescribed medications?

If so, briefly explain. If no, type N/A

Is the family aware that a referral has been made to CCHH?

Yes

Don't Know

How long have sexualized behaviors been occurring?

Age it began?

Any legal concerns with family?

If so, briefly explain

How did family respond to closure of incident(s)?

Summary of behaviors/symptoms:

Please provide a brief explanation of reason for referral

Your information will be encrypted.