Forensic Interview Request

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

Pre-interview call: ________________

Add'l Intake notes:

Date*

MonthDayYear

Hour MinutesAM/PM Option

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*

No Accommodations RequestedCognitive/Communicative/Developmental DelayChild has an IEP at SchoolAccommodations 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*

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)

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 Phone

Cellular number*

Mobile Phone

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

Investigating Jurisdiction

Medical exam*

Has a medical exam been conducted?