Chrysalis Health - The Center for Child Welfare



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BROWARD SHERIFF’S OFFICE

Child Protective Investigations Section (Circuit 17)

Human Trafficking (HT)

Commercially Sexually Exploited Child (CSEC) / Domestic Minor Sex Trafficking (DMST)

Multi-Disciplinary Safe Harbor Assessment Staffing Report

|For Office Use Only |Youth’s L/N:       |Youth’s F/N:       |Youth’s M/N:       |

|Previous CSEC/HT staffed : Yes No |If Yes dates:       |Previous MSST staffed : Yes No |If Yes dates:       |

|FSFN # :       |Date Report:       |Date Staffing:       |Fax: 954-327-2764 |

|CPI:       |Desk: (954)       |Cell #: (954)       |Email:      @ |

|CPI Sup.:       |Desk: (954)       |Cell #: (954)       |Email:      @ |

|1. ALLEGATIONS |

|      |

|2. CURRENT RISKS/CONCERNS (Identified by CPI, LE, or other professionals) |

|      |

| |

|3. DEMOGRAPHICS |

|Youth’s Last Name: |First Name: |Age: |DOB: |Gender: |Race: |

|      |      |      |      |      |      |

|# of Children in family? |

|(All siblings) |

|      |

|In-Home: Yes No |JAC: Yes No |DJJ: Yes No |Youth Shelter: Yes No |

| | |Location:       |Location:       |

|Short Term Safe House: Yes No |Safe House: Yes No |Group Home: Yes No |Foster Home: Yes No |

|Location:       |Location:       |Location:       | |

|Home address:       |City:       |Zip Code:       |Contact #:       |

|School Name/City:       |Grade Level:       |Tardiness: Yes No |Academic difficulties? |

| |GPA:       |Truancies: Yes No |Yes No |

|Family Culture:       |Youth’s Primary Language:       |Parent’s Primary Language:       |

|Parent/Guardian L/F Name: |Local Address: |City: |Zip Code: |Phone#: |

|      |      |      |      |      |

|Parent/Guardian L/F Name: |Local Address: |City: |Zip Code: |Phone#: |

|      |      |      |      |      |

|Does case involve person(s) needing communication assistance? Yes No If Yes, who: Youth Mother Father |

|Caregiver/Other Name:                                     Name:                                     |

|Check all applicable: Deaf or hard of hearing Visually impaired Limited English Proficiency |

|5. RUN-A-WAY YOUTH |

|Has the Youth ever run-a-way? |How many incidents? |How long and where to? |Was LE notified: Yes No |

|Yes No |      |      |How many times:       |

|Active Run-a-way |If Yes, missing persons report filed with LE and entered into FCIC/NCIC? |If Dependent run-a-way - Pick-Up Order |

|Yes No |Yes No LE Case #:       Entered into FCIC/NCIC: Yes No |issued? Yes No |

|Where did the Youth “run to?”       |With whom did the Youth stay with while a runaway?       |

|With whom did the Youth runaway?       |Name of location where the Youth went, e.g. City, State.       |

|6. SERVICES |

|Past Services:       |Case Manager Last/First Name: |Phone#: |

| |      |      |

|Current Services:       |Case Manager Last/First Name: |Phone#: |

| |      |      |

|7. DJJ STATUS |

|Did LE take the youth into custody during this |If Yes, Law Enforcement Agency: |Case Number: |LE Name: |

|investigation? |      |      |      |

|Yes No | | | |

|DJJ Custody? Yes No |Release to Parent/Guardian? Yes No |On House Arrest? |

|Facility:       |Location:       |Yes No |

|BSO Juvenile Assessment Center (JAC) Shared Hope International INTERVENE Screening Tool: |

|JAC Report to Abuse Hotline attached: Yes No |

|Tier 2 Assessment attached: Yes No |

|Psychosocial Assessment attached: Yes No |

|GAIN-Q (QRRS) attached: Yes No |

|List concerns and recommendations from assessment report:       |

|Youth on Probation? |Probation/Court Restrictions? |JPO Last/First Name: |Phone #: |

|Yes No |      |      |      |

|8. DEPENDENCY |

|Adjudicated Dep. Yes |If Yes, court case: |Dependency Case #:       |If Open, CA Last/First Name: |CA Phone#: |

|No |Open Closed |Jurisdiction County:       |      |      |

|Current Placement: | Parent | Relative | Non-Relative | Lic. Placement |

|9. PRIOR ABUSE/NEGLECT/ABANDONMENT HISTORY WITH THE YOUTH AND ANY FAMILY MEMBERS CONNECTED WITH THE YOUTH. (Prior Abuse History with YOUTH and any FAMILY members connected|

|with the YOUTH. List Abuse Report #, each maltreatment and its finding, and intervention/services. Identify if the YOUTH (Y) was the V/C of the abuse report and/or If |

|another child (OC) was the V/C of the abuse report. |

|If extensive prior abuse/neglect/abandonment and a separate report is |FSFN# or Other State:       |

|completed then attach to the HT- CSEC/DMST Safe Harbor assessment |Maltreatment/Finding, and Intervention/Services:       |

|report. |If the YOUTH was the V/C of the report, check Y. |

|If attachment, check box: |If another child was the V/C of the report, check OC. |

|Florida Department of Children and Families | |

|Yes No | |

|Abuse Investigation from another state | |

|Yes No | |

|List state(s):       | |

| |FSFN# or Other State:       |

| |Maltreatment/Finding, and Intervention/Services:       |

| |If the YOUTH was the V/C of the report, check Y. |

| |If another child was the V/C of the report, check OC. |

| |FSFN# or Other State:       |

| |Maltreatment/Finding, and Intervention/Services:       |

| |If the YOUTH was the V/C of the report, check Y. |

| |If another child was the V/C of the report, check OC. |

| |FSFN# or Other State:       |

| |Maltreatment/Finding, and Intervention/Services:       |

| |If the YOUTH was the V/C of the report, check Y. |

| |If another child was the V/C of the report, check OC. |

| |FSFN# or Other State:       |

| |Maltreatment/Finding, and Intervention/Services:       |

| |If the YOUTH was the V/C of the report, check Y. |

| |If another child was the V/C of the report, check OC. |

| |FSFN# or Other State:       |

| |Maltreatment/Finding, and Intervention/Services:       |

| |If the YOUTH was the V/C of the report, check Y. |

| |If another child was the V/C of the report, check OC. |

| |FSFN# or Other State:       |

| |Maltreatment/Finding, and Intervention/Services:       |

| |If the YOUTH was the V/C of the report, check Y. |

| |If another child was the V/C of the report, check OC. |

| |FSFN# or Other State:       |

| |Maltreatment/Finding, and Intervention/Services:       |

| |If the YOUTH was the V/C of the report, check Y. |

| |If another child was the V/C of the report, check OC. |

|Check all maltreatments identified in above section that the YOUTH or | Sexual Abuse | Bone Fracture | Bizarre Punishment |

|any FAMILY member has been investigated. |Physical Injury |Abandonment |Inadequate Supervision |

|This includes out of state prior abuse history, if the youth is |Mental Injury |Asphyxiation |Family Violence TH Child |

|currently in foster care/group home, DJJ facility or has been TPR. |Child-on-Child |Substance Misuse |Malnutrition/Dehydration |

|Additional information:       |Medical Neglect |Failure to Thrive |Environmental Hazards |

| |Threaten Harm |Special Conditions |Excessive Corporal – |

| |Burns |Internal Injuries |Punishment |

| |Death |Neglect |      |

| |Failure to Protect |Human Trafficking |      |

|10. CSEC/DMST IDENTIFYING QUESTIONS |

|For the following sections, please be advised that “no” may also refer to “none reported,” whereas “unknown” is reserved for that information which is not known at the |

|time of this report. |

|10a. Is the youth CURRENTLY experiencing or witnessing any abuse, | Yes No | Physical Abuse | Death Family/Friend |

|neglect, domestic violence and/or other traumatic event? |Unknown |Sexual Abuse |Substance Misuse |

| |If Yes, (Check all |Neglect |Parent’s Separated/Divorce |

| |applicable) |Abandonment |      |

| | |Mental Injury |      |

| | |Bullying |      |

| | |Domestic Violence |      |

| | |Human Trafficking |      |

| | |Additional information:       |

|10b. Is this a vulnerable youth? | Yes No | Throwaway/Abandon | Lock-Out |

| |Unknown |Victim Physical Abuse |Homeless |

| | |Victim Neglect |Delinquent (DJJ) |

| |If Yes, (Check all |Victim Sexual Abuse |Promiscuous |

| |applicable) |Victim Mental Injury |Isolated |

| | |Juvenile Sex Offender |Substance Abuse |

| | |Child on Child |      |

| | |Mental Health |      |

| | |Runaway |      |

| | |Ungovernable |      |

| | |Additional information:       |

|10c. Does the youth break curfew? | Yes No | Keeping late nights |

| |Unknown |Unusual hours |

| | |Youth does not follow house rules (Family home, youth shelter, or group |

| |If Yes, (Check all |home). |

| |applicable) |Explain:       |

|10d. Is the youth secretive? | Yes No | Friends/Acquaintance |

| |Unknown |Unaccounted Time |

| |If Yes, (Check all |Vagueness concerning whereabouts |

| |applicable) |Defensiveness to questions or concerns |

| | |Sneaks out of home |

| | |Explain:       |

|10e. Does the youth have social functioning problems? | Yes No | Poor Social Skills | Social Isolation |

|If Yes, (Check all applicable) |Unknown |Poor Peer Relationships |      |

|10f. Is or has the youth used any drugs/alcohol/substances? | Yes No | Crack | Marijuana | Scizzurp |

| |Unknown |Ecstasy |Cocaine |Meth/Crystal |

| |If Yes, (Check all |Alcohol |Prescription Meds |Rohypnol |

| |applicable) |PCP |Heroine |Bath Salts |

| | |GHB |Amphetamines |      |

| | |K-2 |Xanax |      |

| | |Mollies |Spice |      |

|10g. Did the youth use any substances with the trafficker or supplied | Yes No | Crack | Marijuana | Scizzurp |

|by the trafficker? |Unknown |Ecstasy |Cocaine |Meth/Crystal |

| |If Yes, (Check all |Alcohol |Prescription Meds |Rohypnol |

| |applicable) |PCP |Heroine |Bath Salts |

| | |GHB |Amphetamines |      |

| | |K-2 |Xanax |      |

| | |Mollies |Spice |      |

|10h. Does the youth have a history of mental health DX or instability?| Yes No | Baker Act | Impulse Control Problems |

| |Unknown |Suicidal Ideation |Uncontrollable anger |

|Additional Information:       | |Mood Disorder |Withdrawn/Isolated |

| |If Yes, (Check all |Depression |Reduced Empathy |

| |applicable) |Anxiety |Oppositional Defiant |

| | |Bi-Polar |Criminal behavior |

| | |ADHD |Paranoid |

| | |Hyper vigilance |Youth is fearful |

| | |Lack of eye contact |Inability to trust |

| | |Hyper-sexualization |Self-destructive |

| | |PTSD |      |

| | |Cutting/Mutilation |      |

| | |Substance Abuse |      |

| | |Marchman Act |      |

| | |Additional information:       |

|10i. Does the youth have any current or prior criminal charges? | Yes No | Domestic Battery | Trespassing |

| |Unknown |Resisting Arrest |Burglary |

| |If Yes, (Check all |Obstruction |Loitering |

| |applicable) |Assault |Shoplifting |

| | |Robbery |Fraud |

| | |Battery |DUI |

| | |Agg. Battery |Drug Possession/Sell |

| | |VOP |Prostitution/Soliciting |

| | |Failure to Appear |Disruption/School Function |

| | |Pick-up Order |Concealed/Possession Weapon |

| | |Open Container |      |

| | |Grand Theft |      |

| | |Petty Theft | |

| | |Additional information:       |

|10j. Does the youth have a history of sexual victimization? Explain: | Yes No | Incest | Stranger |

|      |Unknown |Mother’s paramour |Sexually exploited |

| |If Yes, (Check all |Relative |      |

| |applicable) |Friend |      |

| | |Sibling |      |

| | |Acquaintance |      |

|10k. Has or is the youth been a victim in the criminal courts? | Yes No | Sexual Abuse | Neglect |

| |Unknown |Physical Abuse |Witness to crime |

| |If Yes, (Check all |Mental Injury |      |

| |applicable) |Domestic Battery |      |

|10l. Does the youth have a history or current STD’s? | Yes No |If Yes, explain?       |

| |Unknown |Is the Youth receiving medical treatment?       |

| | |Has the Youth received medical treatment?       |

|10m. Is or has the youth been pregnant? | Yes No |If Yes, how many pregnancies?       |

| |Unknown |How many abortions:       |

| | |Where is the youth’s minor child?       |

| | |Is the Department (DCF) involved, explain?       |

|10n. Does the youth have a social networking account or advertising | Facebook | MySpace | Skype | black gay chat |

|account? |Backpage |Craigslist |YouTube |myYearbook |

| |Twitter |Meetup |Flickr |my red book |

|Yes No Unknown |Instagram |Tagged |SnapChat |vampire freaks |

|If Yes, (Check all applicable) |Badoo |Ning |Tumblr |      |

| |Rentboy |Jack’D |Mobli |      |

| |Adam4Adam |Blendr |WhatsApp |      |

| |xanga |sipsap |LINE |      |

| |MoCo |Orkut |KakaoTalk |      |

| |Grindr |myLife |WeChat |      |

| |Scruff |Houseboy |BlackPlant |      |

| |Social Media Name(s):       |

| |Additional information:       |

|10o. Has the youth been exploited on the internet, online ads? | Yes No |If Yes, explain:       |

| |Unknown | |

|10p. Does the youth have an adult boy/girlfriend? | Yes No |If Yes, describe the relationship:       |

| |Unknown |What is the adult boy/girlfriend age?       |

|10q. Is the youth a member of a gang? | Yes No |If Yes, name of gang:       |

| |Unknown | |

|10r. Does the youth have FRIENDS who are members of a gang? | Yes No |If Yes, name of gang:       |

| |Unknown | |

|10s. Has the youth exchanged sexual favors/activity/photos for | Yes No | Shelter | Sexual Favors | Activities |

|necessities and or gifts? |Unknown |Money |Hair/Nails/Clothing |      |

| |If Yes, (Check all |Photos |Cell Phone/Electronics |      |

| |applicable) |Food |Unexplained gifts |      |

| | |Drugs |Social Activities/Clubs |      |

|10t. Does the youth have tattoos and or piercings? |Face:       |RT Upper Arm:       |RT Thigh:       |

| |Front Neck:       |LT Upper Arm:       |LT Thigh:       |

|Yes No Unknown |Back Neck:       |RT Forearm Arm:       |LT Lower Leg:       |

|If Yes, describe tattoo and location on the body. (Check all |Inner Lip:       |LT Forearm Arm:       |RT Lower Leg:       |

|applicable) |Chest:       |RT Hand:       |RT Ankle:       |

| |LT Breast:       |LT Hand:       |LT Ankles:       |

| |LT Breast:       |RT Buttocks:       |LT Foot:       |

| |Upper Back:       |LT Buttocks:       |RT Foot:       |

| |Lower Back:       |Stomach:       |RT Hip:       |

| |Other:       |Other:       |LT Hip:       |

| |Other:       |Other:       |Other:       |

|10u. Is the tattoo associated with something or someone? (pimp, | Yes No |Association?       |

|trafficker, branded, gang, etc.) |Unknown |Relationship?       |

| |If Yes, what is the….? |Name?       |

|10v. Does the youth have a cell phone? | Yes No |Cell #:       |

| |Unknown |If Yes, who pays for this cell phone number?       |

|10w. Does the youth have multiple cell phones? | Yes No |Cell #:       |

| |Unknown |If Yes, who pays for the second/third cell phone number?       |

|10x. Does the youth come home or to the group home with unexplained | Yes No | Clothes | Nails |       |

|clothes, hair, nails, money, gifts, etc.? |Unknown |Shoes |Cell |      |

| |If Yes, (Check all |Gifts |Electronics |      |

| |applicable) |Hair |Jewelry |      |

|10y. Does youth have hotel/motel key cards, business cards, | Yes No | Hotel/Motel Key card(s) |       |

|matchbooks, etc.? |Unknown |Business cards |      |

| |If Yes, (Check all |Matchbooks |      |

| |applicable)) |Taxi/Transportation info |      |

| | |Explain:       |

|10z. Does the youth have knowledge of advanced sexual practices? |Does the youth know how much to charge for different sex acts? |

| |Yes No Unknown |

| |Does the youth use advance language when talking about sex? |

| |Yes No Unknown |

| |Does the youth speak with confidence when using sexual words/language? |

| |Yes No Unknown |

| |Is the youth familiar with the sex industry (lingerie shows, strip clubs, social media, massage |

| |parlors, where to buy sex toys or pornography)? |

| |Yes No Unknown |

| |(Check all applicable) |

| |Pornography Lingerie shows Social media Gangs |

| |Modeling Strip clubs Dance clubs Parties |

| |Other:       |

| |Is the youth comfortable taking her/his clothes off in front of others? |

| |Yes No Unknown |

| |Does the youth lack regard when talking about sex? |

| |Yes No Unknown |

| |Does the youth speak explicitly about sexual acts? |

| |Yes No Unknown |

| |Does the youth use lack of clothing or provocative clothing to attract sexual interest? Yes |

| |No Unknown |

| |What does the youth think about someone who strips or sells her/his body for sex?       |

|10aa. Who involved the youth into sex trafficking (CSEC/DMST) or is | Male Female …… Friend |

|grooming the Youth into sex trafficking (CSEC/DMST). |Male Female …... Relative |

| |Male Female …… Stranger |

| |Male Female …… Acquaintance |

| |Male Female …… Acquaintance in Foster/Youth Shelter/Group Home |

| |Male Female …… Advertisement (name):       |

| |Male Female …… Social Media (name):       |

|10bb. Is the youth controlled by a particular person | Yes No |If Yes, Name/Nickname:       |

|(pimp/boyfriend/girlfriend/firend/acquaintance)? |Unknown | |

|10cc. Was the youth moved to different cities/counties while involved | Yes No |If Yes, which cities/counties?       |

|in CSEC/DMST or HT? |Unknown | |

|10dd. Was the youth taken to multiple locations? | Yes No |If Yes, which ones and by whom?       |

| |Unknown | |

|10ee. Was the youth asked to recruit others? | Yes No |If Yes, explain:       |

| |Unknown | |

|10ff. Does the youth’s PARENT(S), CAREGIVER(S), OR SIBLING(S) have a | Yes No | Baker Act | Impulse Control Problems |

|history of mental health DX or instability? |Unknown |Suicidal Ideation |Uncontrollable anger |

| | |Mood Disorder |Withdrawn/Isolated |

|Additional Information:       |If Yes, (Check all |Depression |Reduced Empathy |

| |applicable) |Anxiety |Oppositional Defiant |

| | |Bi-Polar |Criminal behavior |

| | |ADHD |Paranoid |

| | |Hyper vigilance |Youth is fearful |

| | |Lack of eye contact |Inability to trust |

| | |Hyper-sexualization |Self-destructive |

| | |PTSD |      |

| | |Cutting/Mutilation |      |

| | |Substance Abuse |      |

| | |Marchman Act |      |

|10gg. Does the youth’s PARENT(S), CAREGIVER(S), OR SIBLING(S) have any| Yes No | Battery | Open Container |

|current or prior criminal charges (This includes if the youth is |Unknown |Aggravated Battery |VOP |

|currently in foster care/group home, DJJ facility or has been TPR)? |If Yes, (Check all |Resisting Arrest |Burglary |

| |applicable) |Assault |Loitering |

|Additional information:       |Father |Robbery |Grand Theft |

| |Mother |Homicide/Manslaughter |Petty Theft |

| |Caregiver |Obstruction |Shoplifting |

| |      |Domestic Battery |Fraud |

| |      |Concealed/Possession Weapon Drug |DUI |

| |      |Possession/Sell |Traffic |

| |      |Prostitution/Soliciting |      |

| | |Failure to Appear |      |

| | |Child Abuse/Endangerment |      |

| | |Trespassing |      |

|10hh. Who is the youth closest to in their family? |Community Youth | Mother | PGM | Cousin |

| |Group Home |Father |PGF |GGParent |

| | |MGM |Brother |GodParent |

| | |MGF |Aunt |      |

| | |Sister |Uncle |      |

|10ii. When there is a problem in the house who resolves it? |Community Youth | Mother | PGM | Cousin |

| | |Father |PGF |GGParent |

| | |MGM |Brother |GodParent |

| | |MGF |Aunt |      |

| | |Sister |Uncle |      |

|10jj. Who pays for things in the youth’s house? |Community Youth | Mother | PGM | Cousin |

| | |Father |PGF |GGParent |

| | |MGM |Brother |GodParent |

| | |MGF |Aunt |      |

| | |Sister |Uncle |      |

|10kk. Does youth’s parent/guardian/CA/group home/LE/service provider, | Yes No |If Yes, explain:       |

|etc. suspect the youth of being a sexually exploited victim? |Unknown | |

|Florida Safe Harbor Law: Based on the above questions, is it suspected the youth is being |Suspected CSEC/DMST (the youth has two or more high risk indicators |

|groomed for sex trafficking or the youth is/has been sexually exploited (CSEC/DMST) |identified above): |

|(Commercial Sexual Activity; Sexually Explicit Performance; Pornography)? (“Sexually exploited|Yes No |

|Child” means a dependent Child who has suffered sexual exploitation as defined in s. |Youth is being groomed CSEC/DMST: |

|39.01(67)(g) and is ineligible for relief and benefits under the federal Trafficking Victims |Yes No |

|Protection Act, 22 U.S.C. ss. 7101 et seq.) |Youth is a victim of CSEC/DMST: |

| |Yes No |

|How long has the YOUTH been involved in CSEC/DMST (this includes a youth being groomed)? |Years:       Months:       |

|Additional Information:       |

|11. Complete this section ONLY if the victim youth is a Foreign National and Human Trafficking is suspected. |

|Youth is a: | Foreign National |ICE/Border Patrol |Agent Last Name/First Name: |Phone#: |

|(Check all |Migrant Worker |Notified? |      |      |

|applicable) |Non-Documented Alien |Yes No | | |

|Parent/Guardian L/F Name: |Address: |City/Country: |Phone#: |

|      |      |      |      |

|Is the Pimp/Boy-Girlfriend/John/Trafficker a Foreign National? |DHS (ICE) Notified? Yes No |

|Yes No Unknown |Agent L/F Name:       |

|If Yes, Country:       |Phone #:       |

|HUMAN TRAFFICKING IDENTIFYING QUESTIONS |

|For the following sections, please be advised that “no” may also refer to “none reported,” whereas “unknown” is reserved for that information which is not known at the |

|time of this report. |

|Was the youth recruited for one purpose and forced to engage in some other jobs? | Yes No Unknown |

|Is the youth engaged with irrational work that is not age appropriate or works long hours? | Yes No Unknown |

|Does the youth have freedom of movement? | Yes No Unknown |

|Is the youth’s communications restricted or monitored, can the youth speak on own behalf? | Yes No Unknown |

|Does the youth have possession of his/her identification and/or travel documents? | Yes No Unknown |

|NOTE: If checked YES, who has control of these documents?       | |

|Is the youth’s salary being garnished to pay off a smuggling fee? | Yes No Unknown |

|NOTE: Paying off a fee for smuggling alone is not considered Human Trafficking. | |

|Has the youth been forced to sell drugs, jewelry, magazines on the street? | Yes No Unknown |

|Is the youth in control of his/her money? | Yes No Unknown |

|Does the youth have an excessive amount of cash? | Yes No Unknown |

|Has the youth or the youth’s family been threatened with harm if the youth attempts to escape? | Yes No Unknown |

|Is the youth fearful of law enforcement, child protective investigator (CPI), or government officials? | Yes No Unknown |

|Was the youth coached on what to say to law enforcement, CPI, or government officials? | Yes No Unknown |

|Has the youth been threaten with deportation or law enforcement actions? | Yes No Unknown |

|Has the youth been harmed, are there signs of physical abuse (bruises, black-eyes, cuts, marks, etc.)? | Yes No Unknown |

|Has the youth been deprived of food, water, sleep, medical care or other life necessities? | Yes No Unknown |

|Is the youth living in unusual or substandard living conditions, sleeping/living separately from the “family” (garage, on the | Yes No Unknown |

|floor in a room, etc.)? | |

|Can the youth freely contact friends or family? | Yes No Unknown |

|Is the youth in school? | Yes No Unknown |

|Does the youth have significant gaps in schooling? | Yes No Unknown |

|Is the youth involved in a controlling or dominating relationship, is the youth allowed to speak? | Yes No Unknown |

|Is the youth loyal to the trafficker? | Yes No Unknown |

|Has the youth engaged/groomed in prostitution or commercial sex acts? | Yes No Unknown |

|(If YES, complete all the CSEC questions below). | |

|Is the YOUTH a victim of Human Trafficking? | Yes No | Sex Trafficking |

| |Unknown |Slavery |

| | |Involuntary Servitude |

| | |Peonage (debt slavery or debt servitude) |

|How long has the YOUTH been involved in HT? |Years:       Months:       |

|Additional Information:       |

|12. FSFN POST INDICATORS (Complete only if the youth is in Out of Home Placement) |

|Removal from Home Reasons: |

|Commercial Sexual Exploitation of Child Human Trafficking – Labor Sexual Abuse-Sexual Exploitation |

|Was the most recent CBHA used for a Safe House Assessment? Yes No |

|If “No,” when was a Safe House Assessment completed? CSEC/HT Staffing date:       |

|CSEC Category: Adult Entertainment Prostitution/No Pimp Prostitution/Pimp Recruiter-Prostitution Pimp |

|CSEC Status: Enter in Error Confirmed Involvement No Longer Involved Possible Involvement |

|Method of Confirmation Values: |

|Arrested/Identified by LE Family Disclosure Findings of CPI Self- Disclosed Professional Observation |

|Reason youth was not placed in a “Safe House”: |

|Age of the child required alternative Placement |

|Child has previously been discharged from a “Safe House” facility/placement due to behavioral issues |

|Child placed in an alternative CSEC placement/program |

|Child refused placement in a “Safe House” facility/placement |

|Child’s limited involvement in CSEC required alternative placement |

|Child’s status as a possible CSEC recruiter for prostitution required alternative placement |

|DJJ placement not related to prostitution charges/conviction |

|DJJ placement related to prostitution charges/conviction |

|Language/Cultural considerations required alternative placement |

|Mental health issues required alternative placement |

|No “Safe House” facility/placement available in are for this child’s gender |

|No “Safe House” facility/placement in area |

|No space available in a “Safe House” facility/placement at this time |

|Other |

|Substance abuse issues required alternative placement |

|Commercial Sexual Exploitation Child: | CSEC – General |

| |CSEC – Law Enforcement Interview with Representation |

| |CSEC – Law Enforcement Interview without Representation |

|CSEC/DMST-HT MULTI-DISCIPLINARY ASSESSMENT TEAM OVERALL RECOMMENDATIONS |

|SELF/SCHOOL: |FAMILY: |PEERS: |COMMUNITY: |

|Academic failure |Family management problems |Negative peer affiliation & gang |Lack of involvement in community |

|Lack of commitment to school |Family history of high risk behavior |involvement |Availability of drugs |

|Poor social skills |Family difficulties |Friends who use drugs |Economic deprivation |

|Behavior/frequent suspensions |Parents favorable attitude toward drugs or|Favorable attitude toward criminal | |

|Substance use/abuse |criminal |activity | |

|Behavioral health concerns |activity |Alienation, rebelliousness | |

| |Lack of family involvement |Easily led by others/”Follower” | |

|Previous MSST staffing Yes No |

|Previous CSEC/HT staffing Yes No |

|If Yes, date and recommendations:       |

|Mental Health Dx or instability:       |

|Current Medications:       |

|Previous Medications:       |

|Treatment: |

|A. Counseling:       |

|B. Health Care:       |

|C. Substance Abuse:       |

|D. Educational Opportunities:       |

|Safe Environment for the Youth:       |

|Family (Re-unite families or provide with appropriate guardians):       |

|Risk Factors:       |

|Other:       |

|This assessment report is the result of a Broward Sheriff's Office CPIS trans-disciplinary staffing review focusing on DMST/CSEC and HT minor victims. The resulting |

|information is based on attending parties’ consensus for purposes of safety & service delivery to the CSEC/HT Minor and FAMILY according to January 2013 FSS Safe Harbor |

|Law. |

|CSEC/HT Staffing date:       |

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