Forensic Interview

Referral Form

Referrals for forensic interviews are only accepted from Law Enforcement & Child Protective Services. If you are with one of these entities, please fill out the form to the best of your ability & we will contact you with available times/dates.

If you are not from one of these entities, please email Ami at intake@safeharborcac.org or call 269-673-3791 before making a request.

All fields must be completed, so if any information is not known, please indicate that by typing “unknown.”

Thank you and we look forward to working with you!

"*" indicates required fields

Requested location:*

Your Agency:*

If Other, Please List Agency Location:*

Name of investigating law enforcement or case worker (referring person):*

Referring person's phone number:*

Extension

Phone Contact Preferences

Text

Call

Referring person's email:*

Will the investigating person, named above, be present at the interview (if not who will be the attending replacement)?*

Yes

Please list the name of the Attending Replacement:*

Who else is investigating this case? (name & agency of CPS or LE, please type NA if this is not applicable):*

Please indicate all availability (day of week/times of day available based on assigned shift &/or family urgent need):*

Monday AM

Monday PM

Tuesday AM

Tuesday PM

Wednesday AM

Wednesday PM

Thursday AM

Thursday PM

Friday AM

Friday PM

Child's name:*

Child's Date of Birth*

Child's address:*

Street Address Address Line 2 City State ZIP Code

Primary Language - Child*

Does the child have any accommodation needs (i.e. language barrier, areas of disability &/or mental health concerns that may impact the interview?:*

Yes

Please list accomodations here:*

Who is the LEGAL (not simply custodial and not foster) parent or guardian that has the LEGAL rights to sign for this child?*

(If the legal parent or guardian is not attending the interview, please contact intake@safeharborcac.org to request the required forms.)

Complaint number (both LE & CPS, if applicable & if known):*

Date reported to investigating agency:*

MM slash DD slash YYYY

Has the child been interviewed before?*

No, has not been interviewed previously.

Yes, at Safe Harbor CAC (second + interviews must be approved by Lori Antkoviak)

Yes, at another CAC (second + interviews must be approved by Lori Antkoviak)

Yes, at another location.

If interviewed at another location, please indicate Where and By Whom:*

If interviewed at another CAC, please indicate Where:*

Alleged offender's name:*

Alleged offender's date of birth*

Alleged offender's relationship to child:*

Please describe the alleged offender's current access to the child:*

Non-offending caregiver name:*

*If this person cannot bring the child, please email us indicating who will be bringing the child & how paperwork & signature permissions will be obtained prior to the interview.

Non-offending caregiver date of birth:*

Non-offending caregiver's phone number:*

Non-offending caregiver's email

Non-offending caregiver's relationship to child:*

Primary Language - Non-offending caregiver*

Is the caregiver aware of the allegations?*

Yes

Brief Summary of allegations:*

If additional children within the family need to be interviewed, please e-mail intake@safeharborcac.org the additional name(s), DOB(s), & any information such as caregiver or allegations that is different from the child named above & reference the child named above in the subject line.

Name of person completing this form:*

Please upload the investigative report:

Drop files here or

Max. file size: 64 MB.

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Forensic Interview

Referral Form

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