Interviews are only accepted from Law Enforcement and Michigan Department of Health and Human Services. If you are from one of these agencies, please fill out the form fields below to schedule a Forensic Interview with the Delta Regional Child Advocacy Center. A representative will contact you with instructions within 24 hours of receiving the referral.

Referral Agency

Referral Name

Referral Email

Direct Phone Number for Referral Source

Name of other agency involved, including the name of the specific person the case is assigned to

First Name

Last Name

Other Agency Email (if available)

Other Agency Phone Number (if available)

(###)

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Please List Date and Times Involved Parties are Available

Is this an urgent or emergency interview? (Needs to be conducted ASAP)

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

Child's Name

Child's Date of Birth

Child's Ethnicity

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

Child's Gender

County Child Resides In

County Alleged Incident Occurred

Date Alleged Incident Occurred

Are there any special needs or accommodations necessary for the child or family?

Autism, Speech/Language Impairment, Sensory Disorders, ODD, ADHD, etc.

Alleged Perpetrator's Name

Alleged Perpetrator's Date of Birth

Alleged Perpetrator's Relationship to Child

Is the non-offending caregiver aware of the allegations?

Would you like us to contact the family for scheduling?

Non-Offending Caregiver's Name

Non-Offending Caregiver's Phone Number

Non-Offending Caregiver's Relationship to Child

Summary of Allegations

Please email any reports or documents relevant to the complaint/investigation to: cac@deltaregionalcac.org