Mission Kids Forensic Interview Request Form

Mission Kids Child Advocacy Center Intake Form for Forensic Interview
Referral Source Information

All information below should be that of the person/organization submitting the referral.
Agency referring case to Mission Kids

Other
Intake form completed by

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Law Enforcement Organization Name
Law Enforcement Investigator Name

First NameLast Name
Law Enforcement Investigator phone number
Please enter a valid phone number.Format: (000) 000-0000.
Law Enforcement Investigator email
example@example.com
Law Enforcement Case Number
Office of Children & Youth (OCY) Caseworker Name

First NameLast Name
OCY Caseworker Email
example@example.com
OCY Caseworker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
OCY Case Number
CWIS Number
Name of Assigned District Attorney
Has the case already been charged?
Has an MCAP been requested?
Date MCAP Requested

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has an MCAP been assigned to the case?
Name of assigned MCAP
Is there a PFA involved, or has one been filed?
Does the child/family need help securing transportation to interview at Mission Kids?
Victim/Witness Information

All information below should be that of the victim/witness.
Victim/witness name

First NameLast Name
Is the child a victim or a witness to the allegations?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age at time of referral
Sex assigned at birth
Pronouns
Race/ethnicity

Other
Are interpretation services needed?
Victim/witness language needed for interpretation services

Other
Victim/witness current school
Does/has the victim/witness currently or previously receive(d) any in-school services related to a disability? (i.e. IEP, Life Skills, Special Education, etc.)
Please identify any known services
Does/has the victim/witness currently or previously receive(d) any mental health services?
Please identify the location and purpose for mental health services
Would you like to add an additional victim/witness related to this case? (Please note, this option is for sibling cases only. Additional victims of the same AP who are NOT siblings with the same address/caregivers/etc. will require a separate form to be filled out.)
#2 Victim/witness name

First NameLast Name
Is the child a victim or a witness to the allegations?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does the victim/witness have the same address as the victim/witness listed above?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age at time of referral
Sex assigned at birth
Pronouns
Race/ethnicity

Other
Are interpretation services needed?
Victim/witness language needed for interpretation services

Other
Victim/witness current school
Does/has the victim/witness currently or previously receive(d) any in-school services related to a disability? (i.e. IEP, Life Skills, Special Education, etc.)
Please identify any known services
Does/has the victim/witness currently or previously receive(d) any mental health services?
Please identify the location and purpose for mental health services
Would you like to add an additional victim/witness related to this case? (Please note, this option is for sibling cases only. Additional victims of the same AP who are NOT siblings with the same address/caregivers/etc. will require a separate form to be filled out.)
#3 Victim/witness name

First NameLast Name
Is the child a victim or a witness to the allegations?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does the victim/witness have the same address as the victim/witness listed above?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age at time of referral
Sex assigned at birth
Pronouns
Race/ethnicity

Other
Are interpretation services needed?
Victim/witness language needed for interpretation services

Other
Victim/witness current school
Does/has the victim/witness currently or previously receive(d) any in-school services related to a disability? (i.e. IEP, Life Skills, Special Education, etc.)
Please identify any known services
Does/has the victim/witness currently or previously receive(d) any mental health services?
Please identify the location and purpose for mental health services
Would you like to add an additional victim/witness related to this case? (Please note, this option is for sibling cases only. Additional victims of the same AP who are NOT siblings with the same address/caregivers/etc. will require a separate form to be filled out.)
#4 Victim/witness name

First NameLast Name
Is the child a victim or a witness to the allegations?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does the victim/witness have the same address as the victim/witness listed above?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age at time of referral
Sex assigned at birth
Pronouns
Race/ethnicity

Other
Are interpretation services needed?
Victim/witness language needed for interpretation services

Other
Victim/witness current school
Does/has the victim/witness currently or previously receive(d) any in-school services related to a disability? (i.e. IEP, Life Skills, Special Education, etc.)
Please identify any known services
Does/has the victim/witness currently or previously receive(d) any mental health services?
Please identify the location and purpose for mental health services
Would you like to add an additional victim/witness related to this case? (Please note, this option is for sibling cases only. Additional victims of the same AP who are NOT siblings with the same address/caregivers/etc. will require a separate form to be filled out.)
#5 Victim/witness name

First NameLast Name
Is the child a victim or a witness to the allegations?
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does the victim/witness have the same address as the victim/witness listed above?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age at time of referral
Sex assigned at birth
Pronouns
Race/ethnicity

Other
Are interpretation services needed?
Victim/witness language needed for interpretation services

Other
Victim/witness current school
Does/has the victim/witness currently or previously receive(d) any in-school services related to a disability? (i.e. IEP, Life Skills, Special Education, etc.)
Please identify any known services
Does/has the victim/witness currently or previously receive(d) any mental health services?
Please identify the location and purpose for mental health services
Witness/Victim Household/Family Information

The following information below should be that of the primary parent/caregiver(s). There will be an additional section for secondary or additional parents/caregivers below. Please list the victim/witness' primary legal guardian first in relation to custody agreement. If both parents/caregivers live in the same household, the order in which you list them does not matter.
Legal custody of the victim/witness(es)

Other
Has the victim(s)/witness(es) been removed from the household?
Is there a safety plan in place?
What is the safety plan?
If the victim(s)/witness(es) were removed from the household, please list information for the current caregiver. Current caregiver's full name (if known)

First NameLast Name
Current caregiver's relationship to victim/witness
Current caregiver's phone number (if known)
Please enter a valid phone number.Format: (000) 000-0000.
Current caregiver's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Caregiver #1

If the child has been removed from the household, please provide information for parent/caregiver PRIOR TO REMOVAL.
Parent/Caregiver #1

First NameLast Name
Relationship to the victim/witness
Does this person have legal custody of the victim/witness?

Other
Caregiver #1 Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is the address of the parent/caregiver the same as the address listed previously for the victim/witness?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Race/ethnicity

Other
Are interpretation services needed?
Parent/caregiver language needed for interpretation services

Other
Please list any known learning disabilities and/or mental health concerns
Would you like to add information for parent/caregiver #2?
Parent/Caregiver #2

If the child has been removed from the household, please provide information for parent/caregiver(s) PRIOR TO REMOVAL.
Parent/Caregiver #2

First NameLast Name
Relationship to the victim/witness
Does this person have legal custody of the victim/witness?

Other
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/caregiver #2 address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Race/ethnicity

Other
Are interpretation services needed?
Parent/caregiver language needed for interpretation services

Other
Please list any known learning disabilities and/or mental health concerns
Additional individuals living in victim/witness household

If the child has been removed from the household, please provide information for household members PRIOR TO REMOVAL.
First Name Last Name
Relationship Age Date of Birth
First Name Last Name
Relationship Age Date of Birth
First Name Last Name
Relationship Age Date of Birth
First Name Last Name
Relationship Age Date of Birth
First Name Last Name
Relationship Age Date of Birth
Alleged Offender Information

All information below should be that of the alleged offender. If a form is being submitted for multiple victims/witnesses, please specify which allegations pertain to which child.
Alleged Offender Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alleged offender classification
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age at time of referral
Sex assigned at birth
Pronouns
Race/ethnicity

Other
Please list any known learning disabilities and/or mental health concerns
Relationship to victim/witness (how does the victim/witness know the alleged offender?)
Is the alleged offender a member of the victim/witness' household?
Has the alleged offender been removed from the household?
Is there a safety plan?
Please provide a brief description of the safety plan
Does the alleged offender have a history of prior abuse?
Please provide a brief description of prior abuse history
Alleged Abuse

All information below should be related to the alleged abuse. If a form is being submitted for multiple victims/witnesses, please specify which allegations pertain to which child.
Type of alleged or suspected maltreatment/abuse (please check all that apply)

Other
Timeframe in which alleged abuse occurred
Is there external evidence/information involved (e.g. photos, electronic communication, videos, etc.)
What type of external evidence/information? Please check all that apply.

Other
Details of physical evidence (journals, drawings, etc.)
Details of video evidence (body cam footage, security, etc.)
Details of photo evidence (scene, AP for identification, injuries, etc.)
Details of electronic communication evidence (text messages, chats, etc.)
If you have questions about external evidence/information, please reach out to the Forensic Interviewer Supervisor, Michelle Kline at mkline@missionkidscac.org
Location(s) where abuse occurred, including address(es) if known, and type of location (i.e. victim's home, alleged offender's home, school, etc.)
Summary of allegations
Was a medical exam performed on victim/witness prior to referral?
Date of exam
Date of exam

Name of provider/organization
Name of provider/organization

Address of provider/organization if known
Street Address   Address Line 2   City   State   Zip
Findings of medical exam (if known)
Would you like Mission Kids to schedule a medical exam prior to forensic interview?
Would you like to add an additional alleged offender involved in this case?
Alleged Offender #2 Name

First NameLast Name
Does the alleged offender have the same address as the previously listed alleged offender?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alleged offender classification
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age at time of referral
Sex assigned at birth
Pronouns
Race/ethnicity

Other
Please list any known learning disabilities and/or mental health concerns
Relationship to victim/witness (how does the victim/witness know the alleged offender?)
Is the alleged offender a member of the victim/witness' household?
Has the alleged offender been removed from the household?
Is there a safety plan?
Please provide a brief description of the safety plan
Does the alleged offender have a history of prior abuse?
Please provide a brief description of prior abuse history
Alleged Abuse

All information below should be related to the alleged abuse. If a form is being submitted for multiple victims/witnesses, please specify which allegations pertain to which child.
Type of alleged or suspected maltreatment/abuse (please check all that apply)

Other
Timeframe in which alleged abuse occurred
Is there external evidence/information involved (e.g. photos, electronic communication, videos, etc.)
What type of external evidence/information? Please check all that apply.

Other
Details of physical evidence (journals, drawings, etc.)
Details of video evidence (body cam footage, security, etc.)
Details of photo evidence (scene, AP for identification, injuries, etc.)
Details of electronic communication evidence (text messages, chats, etc.)
If you have questions about external evidence/information, please reach out to the Forensic Interviewer Supervisor, Michelle Kline at mkline@missionkidscac.org
Location(s) where abuse occurred, including address(es) if known, and type of location (i.e. victim's home, alleged offender's home, school, etc.)
Summary of allegations
Was a medical exam performed on victim/witness prior to referral?
Date of exam
Date of exam

Name of provider/organization
Name of provider/organization

Address of provider/organization if known
Street Address   Address Line 2   City   State   Zip
Findings of medical exam (if known)
Would you like Mission Kids to schedule a medical exam prior to forensic interivew?
Additional Information
If you'd like to include any additional information that was not included on this form, please do so here. (Example: preferred date/time for forensic interview, etc.) If not, please submit.
For questions regarding this form or forensic interview scheduling, contact Susan Tymon, Intake Case Coordinator at 484-687-2990 ext. 1010 or by email at scheduling@missionkidscac.org.
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Mission Kids Child Advocacy Center Intake Form for Forensic Interview

Referral Source Information

Victim/Witness Information

Witness/Victim Household/Family Information

Parent/Caregiver #1

Parent/Caregiver #2

Additional individuals living in victim/witness household

Alleged Offender Information

Alleged Abuse

Alleged Abuse

Additional Information