MDT Forensic Interview Request Form

MDT Forensic Interview Request Form
If this is an after-hours or emergency service, please call the 24/7 number: 972-597-7980

Once submitted, the MDT Coordinator will contact you to complete scheduling.
Full Name of person requesting response:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Agency:
Email
example@example.com
I am requesting: select all that apply
Is law enforcement involved?
Law Enforcement Agency:
Detective Name and Contact information:
Report number:
Other time frame information:
LE Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is TDFPS involved?
Full Name of Child Protective Investigator/Caseworker:

First NameLast Name
Full Name of DFPS Investigator Supervisor:

First NameLast Name
Location:
Case number:
DFPS time frame
Priority:
Date:
Time:
Other information:
CPS Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Child/Adult's Full Name

First NameLast Name
Child/Adult's DOB:
Child/Adult's Age:
Child/Adult's biological sex:
Race:
Has child/adult received ECCAC services before?
Language:

Other
Does the child/adult present with any disabilities?
If yes, explain
AP's Full Name

First NameLast Name
AP DOB:
AP age:
AP Race:
AP Biological Sex:
Relationship to the child/adult:
Date of most recent incident, if known:
Does the AP live with the child/adult?
Parent/Guardian's Full Name:

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian address:
Parent/Guardian Language:

Other
Interview Type:
Allegation Type:

Other
Medical Services:
Prior mental health services
If yes to medical or mental health, provide a brief description:
Scheduling
Has caregiver been notified that the ECCAC will be contacting them to schedule the interview?
Any days/times you are unavailable, please note.
Does the caregiver have any criminal history, current investigations or other concerns that would present a safety concern?
Additional Child Information 1: (name, DOB, Language, Disability)
Additional Child Information 2: (name, DOB, Language, Disability)
Should be Empty:

MDT Forensic Interview Request Form

If this is an after-hours or emergency service, please call the 24/7 number: 972-597-7980

Scheduling