Children's Advocacy Center - Forensic Interview Request Form
MDT Team Members Only.
Child's Name
*
Child's First Name
Child's Last Name
Child's DOB
*
-
Month
-
Day
Year
Date
Child's Biological Gender
*
Male
Female
Child's Gender Identity
*
Female
Male
Non-Binary
Child's Race
*
African American
Asian
Caucasian
Hispanic
Native American
Multi-racial
Other
Does the child have a physical disability and/or mental health diagnosis?
*
No
Yes
Please explain (child's disability and mental health diagnosis)
*
Child's Primary Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any impairment with communicating?:
*
Yes
No
Are translation services required?:
*
Yes
No
Is the incident address different from the primary address?:
*
Yes
No
Incident Address (If different from the primary address):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is child in CPS custody?:
*
Yes
No
Legal Guardian Information:
*
First Name
Last Name
Is legal guardian considered an alleged offender?:
*
Yes
No
Legal Guardian (Non-Offending) Contact Number:
*
If LG is considered an alleged offender, please enter CPS worker contact number.
Legal guardian's DOB:
-
Month
-
Day
Year
What is the Legal Guardian's Relationship to child?
*
Biological Father
Biological Mother
Step-Father
Step-Mother
Adoptive Father
Adoptive Mother
Grandparent
Aunt
Uncle
Other
Indicate what type of custody:
*
Full Legal
Joint Custody
Temporary Custody
Safety Plan
Is there an Additional Legal Guardian?:
*
Yes
No
Additional Legal Guardian Information:
*
First Name
Last Name
Is the Additional Legal Guardian considered an Alleged Offender?:
*
Yes
No
Additional Legal Guardian (Non-Offending) Contact Number:
*
If Additional LG is considered an alleged offender, please enter CPS worker contact number.
What is the Additional Legal Guardian's Relationship to child?:
*
Biological Father
Biological Mother
Step-Father
Step-Mother
Adoptive Father
Adoptive Mother
Grandparent
Aunt
Uncle
Other
Who will be bringing the child to the FI appointment? (ALLEGED OFFENDERS ARE NOT ALLOWED ON CHILDREN'S ADVOCACY CENTER PROPERTY)
*
List everyone currently living in the child's primary home
*
Does the child have a second home
*
Yes
No
If applicable list everyone living in the child's second home
*
Back
Next
Does this child have any previous reports with CPS?
*
Yes
No
Please provide previous CPS report details.
Supporting documentation may also be uploaded in the section at the end of this intake form.
Abuse Allegation Type (Please Click all that apply.)
*
Sexual
Physical
Neglect
Drug Endangerment
Witness to a crime
Human Trafficking
Other
Please enter a detailed description of the abuse allegations below:
*
To whom did the child disclose?
*
Alleged Perpetrator Information
*
First Name
Last Name
Alleged Perpetrator DOB
-
Month
-
Day
Year
Date
AP DOB
Unknown
AP's Gender Identity
*
Male
Female
Non-Binary
What is the AP's relation to the child?:
*
Is there an additional AP?:
*
Yes
No
Second Alleged Perpetrator (If Applicable)
First Name
Last Name
Second Alleged Perpetrator DOB
-
Month
-
Day
Year
Date
Second AP's Gender Identity
Male
Female
Non-Binary
What is the second AP's relation to the child?
Are there any additional Alleged Perpetrators other than the above?
*
Yes
No
If Yes, Please list any remaining Alleged Perpetrators, DOB, Gender, Race, and Relationship to child below.
MDT TEAM CONTACT INFORMATION
Please enter the contact information associated with this intake as well as the name and supervisor contact information of the team member who is submitting this form.
Assigned CPS Worker
*
First Name
Last Name
CPS Worker Contact Number
*
Please enter a valid phone number.
CPS Worker's Email Address
*
example@example.com
Assigned Law Enforcement Officer
*
First Name
Last Name
Law Enforcement Agency
*
Law Enforcement Officer's Contact Number
*
Please enter a valid phone number.
Law Enforcement Officer's Email Address
*
example@example.com
Supervisor's Name (of Team Member submitting this intake):
*
First Name
Last Name
Supervisor's Phone Number
*
Please enter YOUR supervisor's phone number.
Team Member submitting this form:
*
First Name
Last Name
Team Member Email submitting this form:
*
example@example.com
Team Member Phone number:
*
Please enter a valid phone number.
Signature of team member:
*
CPS Report Number (For Cross-Reporting):
*
Law Enforcement Report - Case Number (For Cross-Reporting):
*
** If applicable, you MUST ENTER THE OFFICIAL LE REPORT NUMBER IF LE IS INVOLVED. *** TUPELO PD, PRENTISS CO SHERIFF DEPT, BOONEVILLE CITY PD, ALCORN CO SHERIFF DEPT, and CORINTH CITY PD cannot begin to investigate a case until a report has not been filed with their office. ***
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