PSB Assessment

Referral Form

Referrals for Problematic Sexual Behavior (PSB) assessments are only accepted from Law Enforcement & DHHS. If you are with one of these entities, please fill out the form to the best of your ability.

If you are not from one of these entities, please contact our agency at 269-673-3791 before making a request.

All fields must be completed, so if any information is not known, please indicate that by typing “unknown.”

Thank you!

"*" indicates required fields

Is the referred child under the age of 10 years old and acting sexually inappropriate with other children or adults?*

Yes

Is the referred child under the age of 10 years old and displaying sexualized behavior or knowledge that is not age appropriate?*

Yes

If you selected no to both options: Do not complete this form. Please submit a Forensic Interview Referral Form instead.

Is the legal guardian of the child aware of this referral?*

Yes

If no, do not complete this form. Please call the legal guardian to ensure they are interested in this service.

Referring Agency Information

Referring Agency*

Law Enforcement (LE)

Department of Health and Human Services (DHHS)

Name of Investigating Officer or Caseworker*

First Last

Referring Person's Phone Number*

Extension

Referring Person’s Email Address*

Case & Service History

Law Enforcement Complaint Number*

CPS Complaint Number (if applicable)

Date Reported to Investigating Agency*

MM slash DD slash YYYY

Has the child previously received services at Safe Harbor?*

Yes

If yes, please describe*

Other Professionals Involved

Who else is involved with this case?*

(Please include name and agency of additional CPS or LE professionals. Type “N/A” if not applicable)

Child’s Information

Child’s Full Name*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Child’s Home Address*

Street Address City State ZIP Code

Primary Language of Child*

Does the child require any accommodation needs?*

(e.g., language interpreter, disabilities, or mental health concerns impacting the interview)

Yes

If yes, please describe*

Legal Guardian Information

(Must be the legal parent/guardian with the authority to consent to services. Do not list foster or temporary custodial guardians unless they have legal rights.)

Legal Parent/Guardian Name*

First Last

Legal Guardian’s Phone Number*

Legal Guardian’s Email Address (if known)

Foster Care Placement (if applicable)

(Please complete this section if the child is currently placed in foster care.)

Foster Care Worker Name

First Last

Foster Care Worker Phone Number

Foster Care Worker Email Address (if known)

Foster Parent Phone Number

Foster Parent Email Address (if known)

Reason for Referral

Please describe the problematic sexual behavior(s) exhibited by the child*

(Include frequency, context, whether behaviors were directed toward other children, etc.)

Form Completion

Name of Person Completing This Form*

First Last

Date*

MM slash DD slash YYYY

Please upload the investigative report, if available

Max. file size: 64 MB.

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PSB Assessment

Referral Form

Referring Agency Information

Case & Service History

Other Professionals Involved

Child’s Information

Legal Guardian Information

Foster Care Placement (if applicable)

Reason for Referral

Form Completion

Follow Us!

Give Help

Report Child Abuse

Forensic Interview Referral Form

PSB Assessment Referral Form

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PSB Assessment

Referral Form

Referring Agency Information

Case & Service History

Other Professionals Involved

Child’s Information

Legal Guardian Information

Foster Care Placement (if applicable)

Reason for Referral

Form Completion

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Give Help

Report Child Abuse

Forensic Interview Referral Form

PSB Assessment Referral Form

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