Appendix 5 Updated TOJ Template January 2025.pdf

DJS Facility or Office Location Address

Aruna Miller Wes Moore Vincent Schiraldi Lt. Governor Governor Secretary

Phone: 410-230-3100 Toll Free: 1-888-639-7499 TDD: 1-800-735-2258

TRANSFER OF JURISDICTION PSYCHOLOGICAL EVALUATION REPORT (Template)

NAME:

CASE NUMBER:

DATE OF BIRTH:

AGE:

PID:

DATE(S) OF ASSESSMENT:

DATE OF REPORT:

CASE MANAGER:

EXAMINER:

SOURCES OF INFORMATION

• Records Reviewed o Legal records o DJS records to include social history or treatment service plan o Educational records including IEP and disciplinary records o Hospitalization, treatment, previous evaluations, discharge records, etc.

o ASSIST Records

• Clinical interview with youth, date

• Phone interview with parent or guardian, date, or date of attempted contacts if unsuccessful

• Testing Administered/Completed o The Structured Assessment of Violence Risk in Youth (SAVRY) remains the only required measure for TOJ evals (for risk assessment estimates).

o The Wechsler Abbreviated Scale of Intelligence – Second Edition (WASI-II) remains the preferred cognitive/intelligence measure o A trauma screening tool, such as the Childhood Trauma Questionnaire (CTQ), is required.

o Measures of personality, executive functions, anger, behavior, mood disorder symptoms, etc. are at the evaluators’ discretion.

INFORMATION UNAVAILABLE FOR REVIEW

• Bullet point or brief statement of additional information you were unable to review.

IDENTIFYING INFORMATION

Youth name, age, referral source, instant offense(s).

NON-CONFIDENTIALITY NOTIFICATION AND DISCLAIMERS

At the outset of the assessment process, youth and their parent/guardian were informed that this assessment is being conducted under the auspices of the Department of Juvenile Services (DJS) for the purpose of providing information to the Court for a future transfer/waiver hearing. Youth and their parent/guardian were informed that a copy of this report will be sent to the DJS Case Manager, State’s Attorney and youth’s assigned attorney. The non-confidential nature of the assessment was reviewed with youth and their parent/guardian

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410-230-3333 / Toll Free: 1-888-639-7499 / TDD: 1-800-735-2258 Successful Youth• Strong Leaders • Safer Communities who demonstrated a full understanding and agreed to proceed. Furthermore, it was explained to youth and their parent/guardian that this assessment does not constitute a psychologist-patient relationship for treatment. The examiner also disclosed that he could be required to testify regarding the information obtained during this assessment. Furthermore, youth and their parent/guardian were informed of the examiner’s potential duty to warn and role as a mandated reporter.

This report reflects the examiner’s understanding of the current matters based upon the available sources of information. Youth and their parent/guardian were not questioned regarding the alleged instant offense. However, relevant static, dynamic, and contextual risk factors, along with possible protective factors are addressed in this report as applicable. Review of additional information in the future could alter any findings and/or recommendations.

DJS does not include information concerning charges that were handled informally and/dismissed in reports for youth who are pending transfer. Please note that the inclusion of this statement does not necessarily imply youth has such charges, but rather, is meant to note that the legal history presented here might not be exhaustive of youth’s juvenile record.

BACKGROUND INFORMATION

Family/Social History:

Other information worth questioning the youth about and including in this section:

-Information about their neighborhood/ where they grew up -Do they have any strong male/female mentors already present?

-Peer relationships -May also be useful to inquire about the youth’s social media histories.

Legal History:

1. We do not discuss unadjudicated matters or probe for further information about the alleged offense(s). We report the youth is currently facing these charges and move on.

Youth is currently charged with XYZ and is currently detained at …

Youth was previously adjudicated / found facts sustained for XYZ on DATE.

2. You may also discuss previous services the youth has received through DJS without connecting those services to any previous charges.

Example: Youth has previously received the following services through the Department: placement at Victor Cullen Center (dates); CHOICE program (date); home detention/GPS monitoring, etc.

3. It may still be helpful to review the police documents related to the instant offense when they are provided but this information is not to be reported on, questioned about, or considered in your SAVRY rating. There may be some space for considering this information when thinking of diagnosis.

Educational/Vocational History:

It’s important to establish if there is a history of school challenges preceding their legal involvement. Or, if the youth has a solid academic record that can be built upon as a potential strength.

Developmental/Medical History:

-Any relevant family history is also worth noting here.

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Trauma History -As trauma-informed care remains a primary area of focus, provide as much information as you can about any reported trauma or information in the referral packets.

-It is also Ok to provide a brief statement or two indicating if the youth is currently endorsing any symptoms of

PTSD.

-This is because the youth’s trauma history is frequently used to justify keeping them in the juvenile system.

Substance Use History:

-Family substance use history is worth noting also.

Treatment/Evaluation History:

-Any prior history of diagnosis, treatment, hospitalization, previous evaluations, or suicidal attempts, statements, or self-harm. Family mental health history information is useful too.

Mental Status and Behavioral Observations:

Appearance and orientation Anything notable about their appearance Level of focus/distractibility Reported mood, observed affect Any unusual statements or actions Level of participation and cooperation Level of insight Thought process and content Suicidal, homicidal, or self-harm thoughts or behaviors Any testing you deem invalid Validity statement

Interests and Strengths:

As reported by the youth and their parent or guardian.

Testing Results:

Cognitive Functioning -You may choose to use your narrative to put the cognitive score into context here, or hold off until your summary and conclusion section.

Behavioral and Emotional Functioning (including trauma assessment):

Risk Assessment:

The following structured professional judgment measure of risk for violence was completed without including the instant offense: The Structured Assessment of Violence Risk in Youth (SAVRY), a structured professional judgment risk tool focusing on static (fixed) and dynamic (fluid) risk factors associated with future violence, as well as protective factors. Factors considered include: Historical Risk Factors, Social/Contextual Risk Factors, Individual/Clinical Risk Factors, and Protective Factors. Each factor is rated as “Low,” “Moderate,” or “High,” whereas Protective Factors are rated as “Present” or “Absent.” Overall, structured professional judgment is used to determine the final risk estimate, which is rated as “Low,” “Moderate,” or “High.”

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Youth is estimated to pose a Low/Moderate/High risk for future violence in the community without recommended services and supports.

Each evaluators writes up the SAVRY differently but the most effective means of communicating your findings is to make it clear which areas you feel are High risk/critical factors.

Similar to the cognitive section, you can put the ratings in context here, or do so more in your summary and conclusions section.

DIAGNOSTIC IMPRESSIONS (DSM5-TR)

CASE FORMULATION/SUMMARY

Summarize your evaluation findings while also giving your theory of the case.

Consider the 5 transfer factors the court is weighing in its decision. You are not expected to comment on each of these, but you may consider rendering your opinion about them in your summary:

• Age o Mentioning adolescent brain development is OK

• Physical and mental condition o See notes below about putting evaluation information into context

• Amenability to treatment in juvenile institution, program, or facility o Eligibility for a program, willingness to participate, would they benefit more than anything in the adult system

• Nature of the offense o Do you have any opinion about their history of adjudicated offenses or lack of prior history?

• Public safety o Does your risk assessment or diagnostic impressions give you any impressions about public safety?

What do you want the reader to know about their family/social history, school history, etc?

For each diagnosis or notation, provide some context within the formulation.

Examples: Why did you diagnose unspecified disruptive, impulse-control, and conduct disorder instead of conduct disorder?

What are the implications of borderline intellectual functioning? Of Below Average FSIQ?

Also, restate if there was any information that was unavailable for review that would have helped with your formulation of the case.

RECOMMENDATIONS

1. Mention the specific treatment issues that need to be addressed. Example: anger, ADHD symptoms, depression, etc.

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2. Avoid mentioning specific placements or levels of care. This includes removing the language of recommending a “structured setting.” Speak about therapy modalities broadly (a treatment approach emphasizing trauma) rather than specifically (TF-CBT).

3. Make sure the recommendations match the data you’ve presented. Example: Don’t recommend a substance abuse assessment if there is no evidence of a potential substance issue.

4. Recommendation for a psychiatry assessment, not medication.

5. Include an academic and/or vocational goal if possible.

6. Include a goal related to their strengths and interests, if possible.

7. We frequently recommend mentorship but again, consider assessing for if there are already positive mentors/supports the youth identifies.

Signature and contact information