Forensic Interview Request

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MDT email: ______ Collaborate Entry: _________ Scheduled: _____________ Confirmed: _________

Pre-interview call: ________________

Add'l Intake notes:
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Date* This field is required.
Date of Intake
Month
Day
Year
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1
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Hour
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Minutes
AM
AM
PM
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Child’s Name* This field is required.
First Middle (If Available) Last
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Date of Birth
DOB
Month
Day
Year
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Age* This field is required.
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Gender* This field is required.
Please Select
Please Select
Select one:
Female
Male
Other
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Pronouns
Please Select
Please Select
She/Her/Hers
He/Him/His
They/Them/Their
NonBinary
Other
Unknown
Select One:
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Race* This field is required.
Please Select
Please Select
Select one:
African American
Caucasian
Hispanic
Bi-racial
Other
Asian
Bi-racial (African American/Caucasian)
Bi-racial (Caucasian/Hispanic)
Unknown
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Disclosure date* This field is required.
Date the Child FIRST disclosed abuse
Month
Day
Year
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Alleged Type of Abuse* This field is required.
Please Select
Please Select
Select one:
Sexual
Felony Physical
Misdemeanor Physical
Witness
Felony Neglect
Multiple
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Human Trafficking Suspected* This field is required.
Please Select
Please Select
Select one:
Yes
No
12
Drug Endangered Child* This field is required.
Please Select
Please Select
Select one:
Yes
No
13
Child Development* This field is required.
No Accommodations Requested
Cognitive/Communicative/Developmental Delay
Child has an IEP at School
Other
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Does the child take any daily medication
Please Select
Please Select
Select one:
Yes
No
Unknown
15
List medication(s):
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Additional Information
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Legal Guardian* This field is required.
Person with Legal Guardianship
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Legal Guardian's Relationship to Child* This field is required.
Legal Guardian's Relationship to Child
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Is the Legal Guardian Supportive* This field is required.
Please Select
Please Select
Select one:
Yes
No
Unknown
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Will the Legal Guardian accompany Child to Family Crisis Services* This field is required.
Please Select
Please Select
Select one:
Yes
No
CPS transport
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Name/Relationship of Person Transporting* This field is required.
If Legal Guardian is NOT supportive and/or an Alleged Offender
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Person Transporting Phone* This field is required.
If Legal Guardian is NOT supportive and/or an Alleged Offender; Phone number is for current caregiver (if not legal guardian)
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Alleged Perpetrator(s)* This field is required.
If multiple, explain in synopsis of allegations below
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Relationship to Child* This field is required.
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Gender
Please Select
Please Select
Select one:
Female
Male
Unknown
26
Age
*if age unknown, choose from 11 and under; 12-17; 18-24; 25+
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Race
Please Select
Please Select
Select one:
African American
Caucasian
Hispanic
Asian
Biracial
Other
Unknown
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Basic synopsis of allegations and circumstances of disclosure* This field is required.
Allegations
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In order to conduct an interview, we will need consent from the legal guardian.
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Does paperwork need to be emailed to CPS for the legal guardian to complete prior to the interview?* This field is required.
Please Select
Please Select
Yes
No
N/A
Select One:
Paperwork Consent Emailed
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If yes, CPS and/or law enforcement email
example@example.com
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Referring Agency* This field is required.
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Referring Person* This field is required.
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CPS county of Investigation* This field is required.
Please Select
Please Select
Lafayette
Marshall
Panola
Quitman
Coahoma
Tallahatchie
Yalobusha
COURTESY REQUEST
Select One:
County CPS investigation
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Office phone number
Work Phone
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Cellular number* This field is required.
Mobile Phone
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Email
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Mailing Address (for synopsis)- REPORTS ARE MAILED VIA USPS* This field is required.
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Have you Cross-Reported? (you must cross report in order to schedule)* This field is required.
Please Select
Please Select
Select one:
Yes
No
Have you notified your other investigating partner CPS/law enforcement?
40
Other Investigating Agency/Person (Required Joint Investigation Partner) - Name required to schedule* This field is required.
Required
41
Where the Crime Occurred
Please Select
Please Select
Select one:
Lafayette
Marshall
Panola
Yalobusha
Tallahatchie
Quitman
Coahoma
REQUEST FOR COURTESY
Investigating Jurisdiction
42
Medical exam* This field is required.
Please Select
Please Select
Select one:
Yes
No
Scheduled
Unknown
Has a medical exam been conducted?
Should be Empty: