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CAC Services Referral Form

CAC referral submissions are only accepted from Law Enforcement, Tribal Social Services, and Michigan Department of Health and Human Services. If you are from one of these agencies, please fill out the form below in as much detail as possible and our staff will be in touch with you via email. For additional assistance, please contact our Forensic Interviewer at ehdavid@baymills.org 906-322-8944 or our Nurse at kmbalash@baymills.org 906-248-8568

For after-hours emergency medical services please contact 906-322-8944.

 

  If you are NOT from one of these agencies, please refer to the "Report Abuse" page.

CAC Services

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

MDT Information

Client's Information

Child's Date of Birth
Month
Day
Year
Did the allegation occur on a tribal land or other federally governed land (military, etc.)
Yes
No
Unsure

Caregiver and Transport

Is the non-offending caregiver aware of the allegations?
Yes
No
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
Have the allegations occurred within the last 72 hours? Does the perpetrator have access to the child?
Yes
No
Who will contact the family for scheduling?

3095 S. Towering Pines Road 

Brimley, Michigan 49715

​

906-248-8564

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Mashkawizii Child Advocacy Center

Chippewa - Luce - Mackinac

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