CAC Services

Please submit a separate referral for each child involved in a case needing services.

MDT Information

Referring Agency (include county)

Referring Name

Referring Email

Direct Phone Number for Referral Source

Has this been reported to CPS

Yes

No

CPS Name (If applicable)

CPS Agency

CPS Phone Number

Are you aware of another MDT partner in this case? Please share name and contact information

Please List Dates and Times ALL Involved Parties are Available. Please note that all MDT partners should arrive 15 minutes prior.

Who will contact the family for scheduling?

Referral Source

Additional agency named above

Client's Information

Child's Name

Child's Date of Birth

Month

Day

Year

Child's Ethnicity

Child's Address

Child's Gender

Does the family have any Native American Heritage? Please advise which tribe the family may be a member of.

Did the allegation occur on a tribal land or other federally governed land (military, etc.)

Yes

No

Unsure

County Child Resides in

Are there any special needs or accommodations necessary for the child or family? (ASD, Speech/Language Impairment, Sensory Disorders, ODD, Translator, etc.)

Please list any other children in the home under 18 years of age.

Caregiver and Transport

Non-Offending Caregiver's Name

Non-Offending Caregiver's Relationship to Child

Non-Offending Caregiver's Phone Number

Is the non-offending caregiver aware of the allegations?

Yes

No

Who will be transporting the child? What is their relationship to the child?

Transport's Phone Number

Is the transporting person aware of the allegations?

Yes

No

Case Information

CAC Services Requested

Has a previous Medical Examination been conducted by an external organization?

Yes

No

Date first reported

County Alleged Incident Occurred

Date Alleged Incident Occurred

Alleged Perpetrator's Name

Alleged Perpetrator's Date of Birth

Alleged Perpetrator's Ethnicity

Alleged Perpetrator's Gender

Alleged Perpetrator's Relationship to Child

Alleged Perpetrator's last known contact with child/client

Have the allegations occurred within the last 72 hours? Does the perpetrator have access to the child?

Yes

No

Alleged Maltreatment, Select all that apply

Summary of Allegations (include context of disclosure):

Please attach any additional reports or documents relevant to the complaint. DO NOT INCLUDE CSAM PHOTO EVIDENCE.