Direct Referral Form
Date of Referral
*
-
Month
-
Day
Year
Date
Referred By:
*
First Name
Last Name
Phone Number
*
Email
example@example.com
Role In Case/Agency Making Referral:
*
Family Advocate and CAC, DFPS, Detective and Jurisdiction, Therapist, other youth agency, etc.
Services referring to: (select all that apply)
*
Family Advocacy Services
Therapy Services
Darkness to Light Training
Child's Information
Please List Primary Victim in Case
Child's Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Other
Hispanic/Latino Origin?
*
Yes
No
Ethnicity:
*
Please Select
American Indian/ Alaska Native
Asian
Black/ African American
White
Unknown
Native Hawaiian/ Pacific Islander
Other
Primary Language:
*
Relationship to AP:
*
Please Add Any Other Children in the Home That Will Be Needing Services:
Provide Full Name and Date of Birth if known
Are there any special needs of the child/victim? (If yes, please specify)
EX) Physical or mental disability, LGTBQ preferences, etc.
Legal Guardian Information
Legal Guardian's Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Relationship to Victim:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Other
Hispanic/Latino Origin?
*
Yes
No
Ethnicity:
*
Please Select
American Indian/ Alaska Native
Asian
Black/ African American
White
Unknown
Native Hawaiian/ Pacific Islander
Other
Primary Language:
*
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If the child is not currently residing with legal guardian, please provide contact information for the current caregiver.
Name, Date of Birth, and Phone Number
Alleged Perpetrator/ Suspect Information
AP/ Suspect's Name:
*
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
AP's Estimated Age (If DOB Unknown):
Gender:
*
Male
Female
Other
Relationship to Victim:
*
Investigation Information
Type of Abuse/ Allegation (Click all that Apply):
*
Sexual Abuse
Physical Abuse
Child Fatality
Sex Trafficking
Child Witness (please elaborate in case summary)
Forensic Interview Conducted?:
*
Yes
No
Unknown
Not Applicable
Forensic Interview Completed By:
Harmony Home Children's Advocacy Center
Other CAC
Please list other CAC:
Date of Forensic Interview:
-
Month
-
Day
Year
Date
Outcry Made?:
Yes
No
Inconclusive
Unknown
Case Summary:
*
MDT Information
If not applicable or unknown, please skip this section
DFPS Worker (if applicable):
First Name
Last Name
DFPS Email:
example@example.com
DFPS Phone Number:
Please enter a valid phone number.
DFPS Case Number:
Law Enforcement Investigator (If applicable):
First Name
Last Name
LE Phone Number:
Please enter a valid phone number.
LE Email:
example@example.com
Primary Incident Location/Jurisdiction:
LE Case #:
Submit
Should be Empty: