Forensic Interview Request

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

Pre-interview call: ________________ Add'l Intake notes:

Child’s Name

First Middle (If Available) Last

Date of Birth

MonthDayYear

Age

Gender

Pronouns

Race

Disclosure date

MonthDayYear

Alleged Type of Abuse

Human Trafficking Suspected

Drug Endangered Child

Child Development

Accommodations Requested (Interpreter, Physical Limitations, etc.): *explain

Does the child take any daily medication

List medication(s):

Additional Information

Legal Guardian

Person with Legal Guardianship

Legal Guardian's Relationship to Child

Is the Legal Guardian Supportive

Will the Legal Guardian accompany Child to Family Crisis Services

Name/Relationship of Person Transporting

If Legal Guardian is NOT supportive and/or an Alleged Offender

Person Transporting Phone

If Legal Guardian is NOT supportive and/or an Alleged Offender; Phone number is for current caregiver (if not legal guardian)Format: (000) 000-0000.

Alleged Perpetrator(s)

If multiple, explain in synopsis of allegations below

Relationship to Child

Gender

Age

*if age unknown, choose from 11 and under; 12-17; 18-24; 25+

Race

Basic synopsis of allegations and circumstances of disclosure

Allegations

In order to conduct an interview, we will need consent from the legal guardian.

Does paperwork need to be emailed to CPS for the legal guardian to complete prior to the interview?

Paperwork Consent Emailed

If yes, CPS and/or law enforcement email

example@example.com

Referring Agency

Referring Person

CPS county of Investigation

County CPS investigation

Office phone number

Work PhoneFormat: (000) 000-0000.

Cellular number

Mobile PhoneFormat: (000) 000-0000.

Email

Mailing Address (for synopsis)- REPORTS ARE MAILED VIA USPS

Have you Cross-Reported? (you must cross report in order to schedule)

Have you notified your other investigating partner CPS/law enforcement?

Other Investigating Agency/Person (Required Joint Investigation Partner) - Name required to schedule

Required

Where the Crime Occurred (law enforcement jurisdiction)

Investigating Jurisdiction

Medical exam

Has a medical exam been conducted?