Dallas Children's Advocacy Center Referral Services
Date of Referral
*
-
Month
-
Day
Year
Date
Referred By:
Name of Person Making Referral
*
First Name
Last Name
Referring Agency
*
Title
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
We may need to follow up with you for any additional information, what time of day is best to reach out to you?
*
What mode of communication is best for you?
*
Phone Call
Email
Case Information:
Type of Abuse
*
SXAB
PHAB
Witness SXAB
Witness PHAB
Child Fatality
NSUP
Trafficking
PSB
Was a Forensic Interview Completed?
*
Yes
No
Where was the FI Completed?
Have charges been filed?
*
Yes
No
N/A
Unknown
Sexual Abuse Details:
*
Fondling over clothes
Fondling under clothes
Digital Penetration-Vagina
Digital Penetration-Anus
Penile-Vaginal Penetration
Penile-Anal Penetration
Oral to Victim
Oral to Suspect
Exposure by Suspect
Voyeurism by Suspect
Exposure to Pornography
Use of Object in Abuse
Pregnancy of Victim
History of Abortion by Victim
Force Sex Act by Other
One Time Occurrence
Multiple Occurrences
Sexually Acting-Out Behaviors
Other
Physical Abuse Details:
*
Failure to Thrive
Hospitalization
Abusive Head Trauma
Blunt Force Trauma
Fracture to Arm(s)
Fracture to Leg(s)
Fracture to Rib(s)
Fracture to Head
Other
Did the Child make a disclosure?
*
Yes
No
Inconclusive
Unknown
Was a Medical Exam Completed?
*
Yes
No
Inconclusive
Unknown
Please provide a brief summary of the case:
*
Is DFPS Involved?
*
Yes
No
DFPS Caseworker/Investigator Name
*
First Name
Last Name
DFPS Caseworker/Investigator Phone Number
*
Please enter a valid phone number.
DFPS Caseworker/Investigator Email
*
example@example.com
DFPS Case Name
*
DFPS Case Number
*
What priority level is the DFPS Case?
N
P1
P2
I&R
RCCL
Is Law Enforcement Involved?
*
Yes
No
Detective's Name
*
First Name
Last Name
Detective's Phone Number
*
Please enter a valid phone number.
Detective's Email
*
example@example.com
Jurisdiction/Agency
*
Report/Offense Number
*
Is District Attorney Involved?
*
Yes
No
District Attorney's Name
*
First Name
Last Name
District Attorney's Advocate Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Projected Court Date
*
Court Readiness
*
Caregiver:
Caregiver's Name
*
First Name
Last Name
Caregiver's Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Child
*
Hispanic/Latino?
*
Yes
No
Unkown
Race
*
Please Select
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
If Multi-Racial, choose all that apply:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Unknown
Other
Biological Sex
*
Female
Male
Other
Primary Language Spoken
*
Does the Child live with this Caregiver?
*
Yes
No
Other
Is the caregiver the legal guardian of the child?
*
Yes
No
Other
Caregiver's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Caregiver's Email
*
example@example.com
Is Caregiver aware that the referral is being placed?
*
Yes
No
Unsure
Child/Victim:
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Hispanic/Latino?
*
Yes
No
Unkown
Race
*
Please Select
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
If Multi-Racial, choose all that apply:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Unknown
Other
Biological Sex
*
Female
Male
Other
Primary Language Spoken
*
Alleged Offender:
Alleged Offender's Name
*
First Name
Last Name
Alleged Offender's Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Child
*
Hispanic/Latino?
*
Yes
No
Unkown
Race
*
Please Select
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
If Multi-Racial, choose all that apply:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Unknown
Other
Biological Sex
*
Female
Male
Other
PSB Initiator:
PSB Initiator's Name
*
First Name
Last Name
PSB Initiator's Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Child/Victim
*
Hispanic/Latino?
*
Yes
No
Unkown
Race
*
Please Select
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
If Multi-Racial, choose all that apply:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Unknown
Other
Biological Sex
*
Female
Male
Other
Has the PSB initiator been the victim of confirmed previous abuse?
*
Yes
No
Other
I acknowledge that I have notified the PSB Initiator's family of this referral
*
Yes
No
Please upload and additional investigative reports as needed.
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