Appendix 7 Psychosexual Eval Report Template.pdf

Community-Based Behavioral Health Evaluations for Multiple

Regions

Solicitation #: 25-Multi-CS-BH-001 IFB Document

IFB for DEPARTMENT OF JUVENILE SERVICES

Appendix 8. – Psychosexual Evaluation Report Template

CONFIDENTIAL REPORT OF PSYCHOSEXUAL EVALUATION

Date of Report:

Youth’s Name:

Date of Birth:

PID:

Home Address:

Parent/Guardian:

Case Manager:

1. Identifying Information & Reason for Referral

Must provide a physical description of the youth and state the youth’s gender, race/ethnic identity, and current residence.

Must specify the context, source, and reason for the referral.

Must include a statement that the limits of confidentiality have been explained to the youth and a statement that the youth understood what was explained.

2. Documents & Records Reviewed

Must list each of the background documents and records reviewed by the psychologist conducting the evaluation. If information was requested and not received, please note what was requested.

3. Tests Administered

Must list the full name and version of each test with test acronym in parenthesis, e.g., Wide

Range Achievement Test – Third Edition (WRAT-3).

Must indicate the date(s) the test was administered.

4. Persons Interviewed

Must list each person interviewed by name; stipulate whether the interview was face-to-face or by phone, and the person’s title or relations to the youth being evaluated, e.g., mother, father, sister, uncle, surrogate parent, community case manager, etc.

5. Legal History

Must summarize current and past legal problems, charges, convictions, detentions, probations, etc., especially sex offenses or pending charges.

6. Current Residence & Family History

Must include a family-of-origin structure, makeup of current household, stability of the home, frequency and emotional quality of youth’s relationships with parent(s) and other family members, current family problems and stressors (especially from the youth’s perspective), and history of family violence, substance abuse, or mental illness, as well as a summary of the family’s strengths.

7. Education Status and History

Must include the youth’s current school, grade and program (regular or special education) placement, recent and past academic performance, areas of academic difficulty and strength, Solicitation #: 25-Multi-CS-BH-001 IFB Document

IFB for DEPARTMENT OF JUVENILE SERVICES attitude towards academics, perception of themselves as a learner, future educational or career goals, quality of their social relationships with peers and adults in school, and history of school adjustment difficulties and truancy/attendance problem.

8. Substance Use History

Must list each illicit street drug the youth has experimented with or currently uses (to include approximate date of last use) along with the frequency and amount used; provide the same information for alcohol use.

Must list any substance use disorder diagnoses the youth possesses and substance abuse counseling or treatment that has been received. If the youth has received substance abuse counseling, briefly describe the source, helpfulness, duration and type, e.g., outpatient or inpatient/residential, of substance abuse services received. Also document whether the youth feels s/he has a substance use problem and if they are receptive to receiving substance use counseling/treatment.

9. Mental Health History

Must describe the current and previous DSM-5 or ICD-10 disorders.

Must detail the youth’s and family-of-origin’s mental health history, to include diagnoses, hospitalizations, medications, psychotherapy, and treatment compliance. If the youth has received mental health counseling or treatment, treatment compliance and whether or not the youth found the counseling or treatment to be helpful?

Must detail if the youths have a history of suicidal ideation, plans, and attempts, describing the method used and the approximate date of each attempt.

10. Psychosexual History

Must detail, developmentally, the youth’s sexual history to include (but not limited to) types of sexual acts s/he has witnessed (in person or through vicarious means such as TV, literature, etc.), and performed (actual and/or alleged); what (type of person, objects, conversations, fantasies, etc.) the youth finds sexually arousing or stimulating; any history of being sexually assaulted, abused, or inappropriately approached or solicited; what the youth remembers learning about sexual acts, attitudes, and behaviors from his parent(s), other family members, and friends; sexual attitudes, beliefs, and practices of youth’s close friends; history of sexual compulsions or instances when the youth felt s/he was unable to resist acting out a sexual fantasy, urge, or impulse; history of recurring and unwanted sexual thoughts, images, urges, etc.; history of sexual

“thought insertion” or sexual command hallucinations; frequency of sexual arousal and youth’s typical “arousal response” behavior; gang or “group” motivated sexual activity history; sex trafficking history; sexual fears; role substance use/abuse has historically played in sexual thoughts, urges, and/or acts; recurring dreams of a sexual nature; and attitudes about coercive or non-consensual sexual behavior

11. Trauma History

Must describe and provide approximate dates of emotionally and/or physically “traumatic” events the youth has been exposed to. Ascertain and document the emotional, cognitive, and behavioral ramifications of these traumatic experiences. Screen and document the presence of DSM-5 or

ICD-10 PTSD symptoms.

12. Medical Health

Solicitation #: 25-Multi-CS-BH-001 IFB Document

IFB for DEPARTMENT OF JUVENILE SERVICES

Must specify if the youth is under the care of a physician for a medical illness or disorder, a description of the disorder(s) and the medications the youth is taking should be documented in this section.

13. Social History

Must summarize what is known or suspected about the youth with regards to the following:

his/her personal strengths, ability to make and keep friends, perceptions of themselves as likeable or unlikeable, history of painful social rejection, ridicule, teasing, or being bullied, and the presence (or absence) of people they can turn to for support and guidance in times of a crisis or when facing pressing personal problems.

14. Mental Status

Must document the youth’s orientation to person, place, year, month, and day-of-month.

Describe youth’s mood, range (and appropriateness) of affect, thought pattern (for example -logical, loose association, tangential), presence or absence of active delusions, hallucinations, suicidal ideation/impulses/plans, judgment, insight, and ability to take/accept responsibility for his/her own actions. Also, describe youth’s interpersonal comfort/lack-of-comfort with the interpersonal component of the assessment process and clinical impression of youth’s memory, receptive and expressive verbal skills.

15. Behavioral Observations

Must describe any behaviors observed during administration of psychological tests that are of importance in understanding the youth’s attitudes towards test taking, confidence in his/her academic or intellectual problem solving ability, reaction to failure, approach to problem solving, frustration tolerance, degree of motor restlessness, and ability to attend and stay focused on the tests and tasks administered.

The examiner must also state whether s/he feels that the test results obtained can be regarded as a valid or accurate indication of the youth’s current abilities or functioning. Factors, e.g., indifference, severe depression, inability to stay focused, fatigue or heavy drowsiness, etc., undermining the validity of the test results should also be listed under this heading.

16. Cognitive Functioning

Summarize results of intellectual/cognitive assessment conducted by other evaluators or completed during current assessment. MUST have cognitive functioning information in report.

17. Psychosexual Results and Interpretation

Must include the list of psychosexual evaluation tools administered, results, and interpretation of those results. This may include the youth’s ability to grasp or understand moral standards and the laws that govern sexual behavior in society, a summary youth’s attitudes regarding sexuality gleaned from interview and/or use of self-report measures (e.g. Adolescent Cognition Scale

Revised), and a summary of the findings from the Juvenile Sex Offender Assessment Protocol-II

(J-SOAP-II), Protective + Risk Observations for Eliminating Sexual Offense Recidivism

(PROFESOR) or a comparable pre-approved instrument.

18. Risk of Danger to Self or Others

Must specify all information reviewed and obtained, and estimate of youth’s overall risk to self and others. If judged either a “moderate or high” risk, describe what harmful behavior the youth is at risk for committing along with what has been learned about the youth via the evaluation process that supports the “moderate” or “high” risk classification.

Solicitation #: 25-Multi-CS-BH-001

IFB Document

IFB for DEPARTMENT OF JUVENILE SERVICES

19. DSM-5 or ICD-10 Diagnostic Impressions

Must specify diagnostic and clinical findings to include disorder(s) that need further evaluation and “By History” qualifiers for active diagnoses made/treated by other health care providers.

When full diagnostic criteria for a particular disorder have not been met, but the youth is

“positive” for several clinically relevant (those having treatment or management implications) features of the disorder, list this disorder with the qualifier “Features”.

20. Summary of Major Findings & Recommendations

Must provide a narrative summary of the salient evaluation findings with a list of recommendations for each problem area documented or discovered. This section of the report can be conceptualized as a “care-and-management- plan-of-action” (that will often include recommendations for family support, education, and intervention). In addition to itemizing

“treatment” or counseling interventions needed. Recommendations may also include “in-home” or “out of home” residential placement based on which risk factors supported by the findings.

The question of venue of treatment (whether out-patient or in-patient/residential) should minimally take into account the following factors: a) level of supervision/structure/environmental controls the youth needs, b) self and community safety concerns c) accessibility to treatment services needed and d) which type of placement, overall, provides the best opportunity for outcome success. If community placement is recommended, a “community safety plan”, i.e., measures needed to protect potential victims from the youth’s potential for re-offending, must be detailed in this section of the report. The specific name of a residential or community based program should not be stated in the placement recommendation.

If, in the opinion of the examiner, additional testing or referral to another professional -psychiatrist, neuropsychological testing, etc. - is warranted, these types of recommendations should be included in this section.

21. Treatment Receptivity & Prognosis

Must describe the youth’s motivation for or receptivity to treatment; also provide an opinion as to the youth’s likelihood to profit from treatment recommended and any recommendations the examiner feels will increase the likelihood of a successful treatment outcome.

22. Signature, Licensure, and Date

At end of report the examiner must provider his/her signature (with professional degree, e.g., Ph.D., MD, MSW, etc.) and the date the completed report was signed. In addition to a written signature and date, the examiner’s name (first & last), degree, and license type must be typewritten to ensure readability.

Printed Name: _____________________________ Degree: ________________________

Signature: ______________________________ Date: _________________________