OSH REQUEST FOR COMMUNITY EVALUTION

Date of Request: DATE Client: Client Name Current Placement: Placement/Unit	Requestor: Social Worker Requestor Phone: Phone Requestor Email: Email

Supervising agency is requesting the PSRB order an evaluation to the following community program:

County

Name of Agency

Name of recommended placement

Materials included with this request include (attach all required documentation):

☐ Attained conditional release readiness status from risk review on DATE (Required)

☐ Completed Violence Risk Assessment on DATE (Required)

☐ Completed other focused Risk Assessment (e.g. SORA, Neuropsychological, Fire Setting, Stalking)

☐ Completed START on DATE (Required)

☐ Most recent prescriber note DATE (Required)

☐ Release of Information (Required)

☐ Describe other included documentation

Additional Information:

☐ Client has no other ordered evaluations at this time.

☐ Client has other ordered evaluations at Name of Program(s); however, additional evaluations are requested at this time because Explain.

☐ Client is under the PSRB pursuant to ORS 426.701.

☐ Client’s instant offense is Murder.

☐ Please include any known victim information: Explain.

Upon receipt of a completed request, the PSRB will order the evaluation pursuant to our Community Evaluation Process. OSH treatment teams are strongly encouraged to be familiar with state-wide PSRB conditional release placements. Prior to requesting an evaluation, outreach to the prospective community program is highly recommended to discuss goodness of fit considerations, risk-needs-responsivity factors, vacancy timelines, and/or other specialty funding/resource needs.

Complete this form for each placement requested. Please limit requests to two placements at a time.

CMHP independently evaluates for the appropriate level of care.

Complete this section for each placement requested, but the documentation itself only needs to be submitted once.

Evaluation request requires a Board administrative review.

Evaluation request requires a Board administrative review.