MITC Interview Referral Form

WISE MITC Interview Referral

Please complete this form to refer for a Forensic Experiential Trauma Interview (FETI). **Note to law enforcement: all aggravated domestic violence reports should be referred; other domestic assaults or suspected domestic violence may be referred at the discretion of the officer.
Required questions are marked with an asterisk. Any questions without an asterisk may be left blank if the answer is unknown.
What is your name?*
Date of Referral*

MonthDayYear
What is the best way to contact you?*
Please enter your email address or phone number
What agency do you work for?*
What is the case number associated with the referral?
When was the incident reported to law enforcement?
Which town did the incident occur in?
YesNo
YesNo
YesNo
Who is the prosecutor assigned to this case?

Reported Victim Information
Required questions are marked with an asterisk. Any questions without an asterisk may be left blank if the answer is unknown.
What is the reported victim's name?*
What is the reported victim's date of birth?
What is the reported victim's age?
YesNo
If the reported victim is currently housed, what is the address?

Street Address

Street Address Line 2

CityState

Zip Code
What is the best contact information for them?*
No character limit
If there are safety concerns, consider contacting the local crisis agency for advocacy.

WISE Hotline: (866) 348-9473
Vermont Statewide Hotline: (800) 228-7395
Please list any additional contact information you have for them here:
No character limit
What is the reported victim's gender?
What is the reported victim's race/ethnicity?

Additional Information and Documents
Additional information you would like to share:
If you have any additional documents (e.g. affidavits) to share, please upload them here:

Cancelof
Should be Empty:

WISE MITC Interview Referral