Attachment 3 904A.pdf
PDF 402 KB Posted
- Attached to
- COPY OF 5400029640 PSYCHOLOGICAL EVALUAT
- Solicitation number
- 5400029872
- Issued by
- Richland County, South Carolina
About this file
This is a psychological evaluation form template issued by the South Carolina Department of Juvenile Justice (SCDJJ) for use at its Coastal/Midlands/Upstate Evaluation Center. The form, designated 904A and updated in October 2019, serves as the standardized document for conducting psychosocial evaluations or community psychology evaluations of juveniles in the SCDJJ system. The form is designed to collect comprehensive information through multiple sources including interviews with the juvenile and parents, contact with community specialists and Department of Social Services, review of DJJ file information, and psychological testing. The evaluation captures critical areas of assessment including DJJ history and current offense details, family functioning, adolescent functioning across developmental, medical, trauma, placement, school, peer, and community dimensions, mental health symptomatology, psychological assessment results, behavioral observations, cognitive and academic functioning, personality and emotional testing, and psychosexual assessment where applicable for sexual offenses. The form concludes with sections for resiliency factors, summary and conclusions, diagnostic impressions, and recommendations. All evaluations are explicitly marked confidential and include strict notice regarding unauthorized disclosure prohibitions and limitations on information sharing due to potential harm to the juvenile.
The form includes detailed confidentiality warnings and notices that evaluations are not confidential within the SCDJJ system and will be shared with attorneys, family court officials, and SCDJJ personnel. Prior to evaluation, juveniles and parents must be informed of the evaluation's purpose, information types requested, information usage, and mandatory reporting requirements for suspected child abuse or neglect. The form requires documented acknowledgment that juveniles and parents understand confidentiality limitations and consent to evaluation participation. This template serves as the operational document for the broader SCDJJ psychological evaluation services contract solicitation, which involves fixed-price bids for pre-dispositional evaluations, sexual offender risk assessments, pre-adjudicatory waiver evaluations, and waiver testimony services throughout South Carolina.
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Other files
| File | Type | Posted |
|---|---|---|
| Amendment 1.docx | DOCX document | |
| Attachment 1 Form 903A.pdf | ||
| Exhibit A.pdf | ||
| 29640 solicitation.docx | DOCX document | |
| Attachment 2 Form 903B.pdf | ||
| 29640 AWARD POSTING.docx | DOCX document | |
| Attachment 4 909A.pdf | ||
| Attachment 7.pdf | ||
| Attachment 5 909B.pdf |
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Text version
CONFIDENTAL
SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE
COASTAL/MIDLANDS/UPSTATE EVALUATION CENTER PSYCHOSOCIAL EVALUATION
OR
COMMUNITY PSYCHOLOGY EVALUATION
904A 10-2019
Name: DOB:
JJMS #: Date(s) of Evaluation (Commitment):
Evaluator(s): Date of Report:
County: Community Specialist:
REFERRAL STATEMENT:
NOTICE:
This report is meant only for the use of qualified professionals and others involved from a legal perspective with this psychological evaluation for disposition. No unauthorized disclosure of this report or information contained in this report is allowed and any person who, without proper authorization, discloses information contained in this report assumes all liability associated therewith. Some individuals and family members may tend to misunderstand and/or distort the information presented herein, which could result in significant stress to the individual or may interfere with rehabilitative services. For individuals with certain mental health or behavioral issues, the consequences of disclosure may be serious. Release should be limited to only that information which is pertinent to the needs of the requesting party. Prior to release to parents/caregivers, the evaluation should first be explained thoroughly by a qualified professional.
Before beginning the evaluation, juvenile and parent(s), were informed of the purpose of the evaluation, what type of information would be requested, and how it would be used. They were also told that the results of the evaluation were not confidential and would be shared with the attorneys, family court officials, and South Carolina Department of Juvenile Justice (SCDJJ) personnel. They were informed that suspected child abuse or neglect must be reported to the proper authorities. Juvenile and parent(s) indicated that they understood the limits of confidentiality and expressed their willingness to cooperate with the evaluation.
SOURCES OF INFORMATION:
Interview with juvenile Interview with parent Contact with Community Specialist Contact with DSS Other Contacts DJJ file information (covers all collateral info documents, including mental health, school, etc) Psychological Testing (only those administered in this evaluation)
DJJ HISTORY AND SUMMARY OF CURRENT OFFENSE(S)
JUVENILE/PARENT ACCOUNT OF THE CURRENT OFFENSE(S)
(For sexual risk assessments, just state “See Psychosexual Assessment for this information”)
CONFIDENTAL
SOUTH CAROLINA DEPARTMENT OF JUVENILE JUSTICE
COASTAL/MIDLANDS/UPSTATE EVALUATION CENTER PSYCHOSOCIAL EVALUATION
OR
COMMUNITY PSYCHOLOGY EVALUATION (cont.)
904A 10-2019
FAMILY FUNCTIONING
Parent/Guardian
Siblings; Other relevant family members
Who is living in the home
Family dynamics
Relevant community/environmental factors
ADOLESCENT FUNCTIONING
Relevant History
Developmental History
Medical History
Trauma History
Placement History
School Functioning
Peer Relations
Community Functioning
Adjustment to Evaluation Center (for secure evaluations)
Mental Health Symptomatology
Psychological Assessment and Interpretation Behavioral Observations/Mental Status
Cognitive and Academic Functioning
Personality/ Emotional Testing
Psychosexual Assessment (Only for offenses that are sexual in nature)
RESILIENCY FACTORS
SUMMARY AND CONCLUSIONS
DIAGNOSTIC IMPRESSIONS
RECOMMENDATIONS
File details come from the government source that posted it. Updated .