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 Name
Last Name
Phone Number
Please enter a valid phone number.
Agency:
Please Select
DFPS
Ellis County Sheriff's Office
Cedar Hill Police
Ennis Police
Ennis ISD Police
Ferris Police
Ferris ISD Police
Garrett Police
Glenn Heights Police
Grand Prairie Police
Italy Police
Mansfield Police
Maypearl Police
Maypearl ISD Police
Midlothian Police
Milford Police
Ovilla Police
Palmer Police
Red Oak Police
Red Oak ISD Police
Waxahachie Police
Other
Email
example@example.com
I am requesting: select all that apply
Forensic Interview
Family Advocacy
Mental Health
Case Review
High Risk Youth
Is law enforcement involved?
yes
no
Law Enforcement Agency:
Please Select
Ellis County Sheriff's Office
Cedar Hill Police
Ennis Police
Ennis ISD Police
Ferris Police
Ferris ISD Police
Garrett Police
Glenn Heights Police
Grand Prairie Police
Italy Police
Mansfield Police
Maypearl Police
Maypearl ISD Police
Midlothian Police
Milford Police
Ovilla Police
Palmer Police
Red Oak Police
Red Oak ISD Police
Waxahachie Police
Other
Report number:
Date:
Time:
Other time frame information:
LE Phone Number
Please enter a valid phone number.
Is TDFPS involved?
Yes
No
Full Name of Child Protective Investigator/Caseworker:
First Name
Last Name
Full Name of DFPS Investigator Supervisor:
First Name
Last Name
Location:
Case number:
DFPS time frame
Priority:
Date:
Time:
Other information:
CPS Phone Number
Please enter a valid phone number.
Child/Adult's Full Name
First Name
Last Name
Child/Adult's DOB:
Child/Adult's Age:
Child/Adult's biological sex:
Female
Male
Race:
Has child/adult received ECCAC services before?
Yes
No
Unknown
Language:
English
Spanish
Other
Does the child/adult present with any disabilities?
no
yes
If yes, explain
AP's Full Name
First Name
Last Name
AP DOB:
AP age:
AP Race:
AP Biological Sex:
Female
Male
Unknown
Relationship to the child/adult:
Date of most recent incident, if known:
Does the AP live with the child/adult?
Yes
No
Unknown
Parent/Guardian's Full Name:
First Name
Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian address:
Parent/Guardian Language:
English
Spanish
Other
Interview Type:
Victim
Witness
Risk
Type option 4
Allegation Type:
SXAB
PHAB
Neglect
Witness - DV/IPV
CST
Other
Medical Services:
Yes
No
Unknown
Prior mental health services
Yes
No
Unknown
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?
Yes
No
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?
Yes
No
Additional Child Information 1: (name, DOB, Language, Disability)
Additional Child Information 2: (name, DOB, Language, Disability)
Submit
Should be Empty: