Forensic Interview Referral Form – Child Advocacy Center of Aiken County

Today’s Date: *

Your Name and Agency: *

Has this incident been cross-reported? *

"Joint investigation and cooperation between law enforcement and DSS is vital to the goal of protecting the child and preparing a solid court case. It is DSS policy that DSS shall request a joint investigation with law enforcement for all serious and/or complex reports of abuse or neglect (including but not limited to sexual abuse, severe physical abuse, serious injury, child death, near fatality, and chronic severe neglect) and shall conduct joint investigations as outlined by local protocol (f/k/a Child Abuse Protocol)." (South Carolina Child Abuse Response Protocol, Sec. 3, Pg. 18)

Child’s Name: *

First

Middle

Last

Child’s Age: *

Child’s DOB: *

Child’s Social Security Number:

Child’s Sex: *

Child’s Gender Identity:

Child’s Race/Ethnicity: *

Does the client or custodian(s) have special needs that we need to be aware of? *

i.e. disability, language barrier, transportation

Child’s Address: *

(Street, Apt., City, State, Zip)

Who is the child currently living with? *

Child's Health Insurance Company and policy number? *

Health Insurance Policy Holder Name and date of birth: *

Contact Person Name: *

***This person CANNOT be an alleged offender.***

Relationship to Child: *

Biological Mother
Biological Father
Step Mother
Step Father
Other

DSS Secondary policy

Home Address *

Primary Phone: *

Secondary Phone:

Email:

Biological Mother Name and Address:

Biological Father Name and Address:

Other Person(s):

Step parents, foster parents, safety plan guardian, etc.

Will someone other than the contact person be transporting the child? If yes, who? *

Alleged Offender Name: *

Alleged Offender Age: *

Alleged Offender Race: *

Alleged Offender Relationship to Client: *

Date of Last Allegation(s): *

DSS Agency: *

DSS Caseworker Name: *

DSS Caseworker Email Address: *

DSS Caseworker Primary Phone: *

Is DSS the primary refferal source? *

Law Enforcement Agency: *

LE Investigator Name: *

LE Investigator Email Address: *

LE Investigator Primary Phone: *

LE Case Number: *

Is LE the primary referral source? *

Please select one or more services you are requesting for this child. *

Forensic Interview
Forensic Medical
Therapy/ Counseling Services
Other

Assault Type: *

Sexual Assault
Physical Assault
Emotional Assault
Domestic Violence
Witness to Domestic Violence
Drug Endangerment
Neglect
Witness to Homicide/ Suicide
Other

Summary of Allegation(s):

*Pursuant to South Carolina Code* Please upload the incident report and any other additional documents by visiting this link (Incident Report, Safety Plan, IEPs, Photos/Screenshots, Videos, etc.): https://cacofaiken-my.sharepoint.com/:f:/g/personal/lford_cacofaiken_org/Eo2KfSJTRqpLnSAFdkMWnjMBFQn97opdPhYCF34DBaL7Ig *

Uploaded
I have no supporting documents to upload.

Please be sure to title your supporting documents with the first and last name of the child. If you are requesting multiple interviews for a case, you only need to submit the intake/supporting documents in one of the submissions.

What were the circumstances of the disclosure? *

Child disclosed/revealed abuse
Child displayed behaviors
Abuse was witnessed
Results of medical exam
Perpetrator confession
Other

Were there any previous services given by other agencies? *

If "yes" to the previous question, please explain. *

Enter N/A if not applicable.

Has an exam been conducted by a Sexual Assault Nurse Examiner (SANE)? *

The SANE Exam is a way to collect evidence that may be on a victims' body from a sexual assault. This exam is usually conducted in an emergency room (ER) setting.

If yes, date and location of medical exam.

Sexual Assault Kit Completed? *

If yes, date and location of sexual assault kit. *