MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION CHILDREN WITH PROBLEM SEXUAL BEHAVIORS ASSESSMENT TOOL
CASE DATA
Incident Number	County	Allegations Of Weapons/Serious Physical Injury
Case Name	Children’s Service Worker
CHILD’S DATA
Name	DOB	Last Four Digits Of SSN:
DCN	Caregiver’s Name	Caregiver’s Relationship
Does The Child Live In Multiple Households? Yes No	Address	Address
PARENTS
Parent 1	Birth date	Parent 2	Birth date
Address	Address
DCN	Phone	DCN	Phone
SIBLINGS
Child’s Name	DCN	Birth Date	Child’s Name	DCN	Birth Date
List children with native American heritage (specify tribe).
OTHER HOUSEHOLD MEMBERS/SIGNIFICANT OTHERS
Name	Birth Date	Relationship To Child
REASON FOR REPORT
Provide a brief description of the incident(s):
What was the specific problematic sexual behavior (list each)?
When did the incident(s) occur?	Where did the incident(s) occur?
How was the behavior discovered?	How many times has the behavior occurred?
Describe any aggression, threat, force, and/or use of coercion by this child:
VICTIM(S)
Name	Sex	Age	Relationship To Child
Describe how the child obtained access to the victim(s):
HISTORY
Is there any history of sexual abuse in the family? Yes No If yes, explain:
Has the child been sexually abused? Yes Suspected No
If yes or suspected, by whom?	Relationship:	How old was the child?	How long did abuse continue?
Describe the sexual abuse:
Has the child been physically abused? Yes Suspected No
If yes or suspected, by whom?	Relationship:	How old was the child?	How long did abuse continue?
Describe the physical abuse:
Has the child been emotionally abused? Yes Suspected No
If yes or suspected, by whom?	Relationship:	How old was the child?	How long did abuse continue?
Describe the emotional abuse:
Has the child been neglected? Yes Suspected No
If yes or suspected, by whom?	Relationship:	How old was the child?	How long did abuse continue?
Describe the neglect:
Has the child witnessed domestic violence? Yes Suspected No If yes, describe the domestic violence (individuals involved, duration, what was witnessed, etc.)
Has the child used alcohol, tobacco, or drugs? Yes Suspected No If yes, describe the substance use (what, duration, frequency, etc.)
Does the child’s parent/caregiver have a history of substance abuse? Yes Suspected No If yes, describe the substance abuse (who, what, duration, frequency, etc.)
Has the child ever been aggressive? (i.e. harm to pets, physical fights, vandalism, etc.) Yes No If yes, describe the aggression (what, age of onset, duration, frequency, etc.)
Has the child been exposed to pornography or witnessed sexual acts? Yes Suspected No If yes describe the exposure (individuals involved, duration, what was witnessed, etc.)
ACCESS TO OTHER CHILDREN
Are there any other vulnerable children in the child’s home? Yes No If yes, explain:
Does the child have any caretaking responsibilities of siblings? Yes No
Describe the sleeping arrangements in the child’s home:
Does the child baby-sit children outside the home? Yes No
Is the child involved in extracurricular activities? Yes No
Does the child spend time with friends outside of school? Yes No
FAMILY COMPOSITION
Describe the child’s relationship with parent 1:
Describe the child’s relationship with parent 2:
If the child does not reside with a parent, describe their relationship with their caregiver:
Describe the child’s relationship with each sibling:
DAYCARE/SCHOOL
Has the child had any behavior problems in daycare or school? Yes No
Has there been any concern for sexual behaviors in daycare or school? Yes No
Describe the behavior problems:
When did the behavior problems begin?
What has the daycare or school done to address the behavior problems?
Describe the child’s academic performance:
Does the child have an IEP? Yes No If yes, what for? (emotional disturbance, other health impairment, developmental delay, speech or language impairment, etc)
CHILD VULNERABILITIES
Does the child have any medical problems? Yes No If yes, describe:
Does the child have any developmental delays (physical, social, emotional, cognitive, language/communication)? Yes No If yes, describe:
Does the child have any mental health concerns? Yes No If yes, describe:
Any mental health diagnoses:	Any medication:
Does the child have any behavioral problems in the home? Yes No If yes, describe:
Does the child have any sleep problems? Yes No If yes, describe:
Describe the child’s peer relationships:
Who are the child’s friends and how old are they?
What are the parent/caregiver’s perceptions of the child’s strengths?
CAREGIVER PROTECTIVE CAPACITIES
Describe each parents/caregivers’ perception of the reported concern:
Have similar concerns been reported or discovered in the past? Yes No If yes, describe the concerns, who was involved, who discovered, what steps have been taken in the past?
Now that the child’s parents/caregivers are aware of the reported concern what, if any, action are they taking?
Describe the family’s support system (formal, informal, etc.):
How do the child’s parents/caregivers control access to media?
How does the child’s parents/caregivers handle discussions about sexual development?
What are the family rules or expectations about privacy, modesty, and personal boundaries?
OTHER STRENGTHS OR CONCERNS
SUMMATION OF SERVICE PLANS, CONCERNS, AND RECOMMENDATIONS
If a weapon or serious injury was involved, was a referral made to the juvenile office? Yes No If no, why not?
SIGNATURES
CHILDREN’S SERVICE WORKER >	DATE
SUPERVISOR>	DATE