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*

Law Enforcement OrganizationOffice of Children and YouthOther
Intake form completed by*

First NameLast Name
Phone Number*
Please enter a valid phone number.
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.
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.
OCY Case Number
CWIS Number
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?*

VictimWitness
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Who does the phone number above belong to?*

Victim/witnessCaregiver of victim/witnessUnknownOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age at time of referral*
Sex assigned at birth*

MaleFemale
Pronouns

He/him/hisShe/her/hersThey/them
Race/ethnicity*

Asian American/Pacific IslanderAmerican Indian/Alaskan NativeBiracialBlack/African AmericanHispanic/LatinoMiddle EasternWhite/CaucasianUnknownOther
Are interpretation services needed?*

No, the victim/witness speaks EnglishYes
Victim/witness language needed for interpretation services*

SpanishOther
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.)*

YesNoUnknown
Please identify any known services
Does/has the victim/witness currently or previously receive(d) any mental health services?*

YesNoUnknown
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)*

YesNo
Victim/witness name*

First NameLast Name
Is the child a victim or a witness to the allegations?*

VictimWitness
Date of Birth*

MonthDayYear
Date
Does the victim/witness have the same phone number as victim/witness listed above?*

YesNo, I would like to add a new phone number
Phone Number
Please enter a valid phone number.
Who does the phone number above belong to?

Victim/witnessCaregiver of victim/witnessUnknownOther
Does the victim/witness have the same address as the victim/witness listed above?*

YesNo, I would like to add a new address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age at time of referral*
Sex assigned at birth*

MaleFemale
Pronouns

He/him/hisShe/her/hersThey/them
Race/ethnicity*

Asian American/Pacific IslanderAmerican Indian/Alaskan NativeBiracialBlack/African AmericanHispanic/LatinoMiddle EasternWhite/CaucasianUnknownOther
Are interpretation services needed?*

No, the victim/witness speaks EnglishYes
Victim/witness language needed for interpretation services*

SpanishOther
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.)*

YesNoUnknown
Please identify any known services
Does/has the victim/witness currently or previously receive(d) any mental health services?*

YesNoUnknown
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)*

YesNo
Victim/witness name*

First NameLast Name
Is the child a victim or a witness to the allegations?*

VictimWitness
Date of Birth*

MonthDayYear
Date
Does the victim/witness have the same phone number as victim/witness listed above?*

YesNo, I would like to add a new phone number
Phone Number
Please enter a valid phone number.
Who does the phone number above belong to?

Victim/witnessCaregiver of victim/witnessUnknownOther
Does the victim/witness have the same address as the victim/witness listed above?*

YesNo, I would like to add a new address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age at time of referral*
Sex assigned at birth*

MaleFemale
Pronouns

He/him/hisShe/her/hersThey/them
Race/ethnicity*

Asian American/Pacific IslanderAmerican Indian/Alaskan NativeBiracialBlack/African AmericanHispanic/LatinoMiddle EasternWhite/CaucasianUnknownOther
Are interpretation services needed?*

No, the victim/witness speaks EnglishYes
Victim/witness language needed for interpretation services*

SpanishOther
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.)*

YesNoUnknown
Please identify any known services
Does/has the victim/witness currently or previously receive(d) any mental health services?*

YesNoUnknown
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)*

MotherFatherSharedOther
Has the victim(s)/witness(es) been removed from the household?*

YesNo
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.
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?*

Sole custodyShared custodyUnknownOther
Caregiver #1 Date of birth

MonthDayYear
Date
Is the address of the parent/caregiver the same as the address listed previously for the victim/witness?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the phone number of the parent/caregiver the same as the address listed previously for the victim/witness?*

Yes
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Race/ethnicity*

Asian American/Pacific IslanderAmerican Indian/Alaskan NativeBiracialBlack/African AmericanHispanic/LatinoMiddle EasternWhite/CaucasianUnknownOther
Are interpretation services needed?*

No, the caregiver speaks EnglishYes
Parent/caregiver language needed for interpretation services*

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

Yes, there is an additional parent/caregiverNo, the victim, witness only has one parent/caregiver to list
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?*

Sole custodyShared custodyUnknownOther
Date of birth

MonthDayYear
Date
Is the address of the parent/caregiver the same as the address listed previously for the victim/witness?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the phone number of the parent/caregiver the same as the address listed previously for the victim/witness?*

YesNo
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Race/ethnicity*

Asian American/Pacific IslanderAmerican Indian/Alaskan NativeBiracialBlack/African AmericanHispanic/LatinoMiddle EasternWhite/CaucasianUnknownOther
Are interpretation services needed?*

No, the caregiver speaks EnglishYes
Parent/caregiver language needed for interpretation services*

SpanishOther
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.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select one*

Adult perpetratorJuvenile actor childUnknown
Date of birth

MonthDayYear
Date
Age at time of referral
Sex assigned at birth*

MaleFemale
Pronouns

He/him/hisShe/her/hersThey/them
Race/ethnicity*

Asian American/Pacific IslanderAmerican Indian/Alaskan NativeBiracialBlack/African AmericanHispanic/LatinoMiddle EasternWhite/CaucasianUnknownOther
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?*

YesNo
Has the alleged offender been removed from the household?*

YesNo
Is there a safety plan?*

YesNo
Please provide a brief description of the safety plan*
Does the alleged offender have a history of prior abuse?*

YesNoUnknown
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)*

Sexual abusePhysical abuseHuman trafficking (HT) / Commercial Sexual Exploitation of Children (CSEC)Internet Crimes Against Children (ICAC) / Child Sexual Abuse Material (CSAM)Child Endangerment/NeglectDrug EndangermentWitness to Sexual AbuseWitness to Physical AbuseWitness to Violence (i.e. DV, Homicide)Other
Timeframe in which alleged abuse occurred*
Is there external evidence involved (i.e. images, electronic communication)*

YesNoUnknown
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?*

YesNoUnknown
Would you like Mission Kids to schedule a medical exam prior to forensic interivew?

YesNo
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 to add an additional alleged offender involved in this case?*

YesNo, there is only one alleged offender involved in this case
Name*

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

YesNo, I would like to add a new address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select one*

Adult perpetratorJuvenile actor childUnknown
Date of birth

MonthDayYear
Date
Age at time of referral
Sex assigned at birth*

MaleFemale
Pronouns

He/him/hisShe/her/hersThey/them
Race/ethnicity*

Asian American/Pacific IslanderAmerican Indian/Alaskan NativeBiracialBlack/African AmericanHispanic/LatinoMiddle EasternWhite/CaucasianUnknownOther
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?*

YesNo
Has the alleged offender been removed from the household?*

YesNo
Is there a safety plan?*

YesNo
Please provide a brief description of the safety plan*
Does the alleged offender have a history of prior abuse?*

YesNoUnknown
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)*

Sexual abusePhysical abuseHuman trafficking (HT) / Commercial Sexual Exploitation of Children (CSEC)Internet Crimes Against Children (ICAC) / Child Sexual Abuse Material (CSAM)Child Endangerment/NeglectDrug EndangermentWitness to Sexual AbuseWitness to Physical AbuseWitness to Violence (i.e. DV, Homicide)Other
Timeframe in which alleged abuse occurred*
Is there external evidence involved (i.e. images, electronic communication)*

YesNoUnknown
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?*

YesNoUnknown
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?

YesNo
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; has an MCAP been assigned to the case, etc.) If not, please submit.
Please verify that you are human*
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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