Forensic Interview Form (Page 2 of 3) in pdf

O.C.G.A. § 17 -15-16 provides that a forensic interview may be paid for by the Forensic Interview Program for crimes occurring in Georgia on or after July 1, 2014. The Forensic

Interview Program can pay up to $200.00 per victim, per victimization (when funding is available) if the interview is for a person who is less than 18 years of age or a

developmentally disabled adult, the interview is conducted in the context of a multidisciplinary and diagnostic team, or in a specialized setting such as a child advocacy center;

and the results of the interview will be for the identification of the interviewee’s needs, including, but not limited to social services, personal advocacy, case management,

substance abuse treatment, and mental health services.

SECTION 1.

In this section, please provide information about the victim.

VICTIM’S INFORMATION

Victim Name (First, Middle, Last)

Victim Gender

Victim Date of Birth (MM/DD/YY)

□ Male  Female

Victim Social Security Number (or TIN)

If 18 or older, is the victim developmentally disabled?

Yes No

Demographic Data (For Statistical Use Only)

 American Indian/Alaska Native  Asian

 Black/African American

 Native Hawaiian and Other Pacific Islander

RACE:

 White/Non-Latino/Caucasian

 Hispanic/Latino

 Other Race____________________

If 17 or older, is the victim a veteran? Yes No Is the victim disabled? Yes No If yes, is the disability as a result of the crime? Yes No

SECTION 2.

In this section, please provide information about the Victim’s Parent/Legal Guardian or

VICTIM’S PARENT/LEGAL GUARDIAN INFORMATION

caregiver.

Victim’s Parent/Legal Guardian Name (First, Middle, Last)

Best Contact Phone Number

Relationship to Victim

Street Address (including apartment #)

City

State

Zip Code

Demographic Data (For Statistical Use Only)

 American Indian/Alaska Native  Asian

 Black/African American

 Native Hawaiian and Other Pacific Islander

RACE:

 White/Non-Latino/Caucasian

 Hispanic/Latino

 Other Race____________________

Is the victim's parent/legal guardian a veteran? Yes No

Is the victim's parent/legal guardian disabled? Yes No

Completing the below section is optional if you include a police /incident report, a FI Law

SECTION 3.

Enforcement or DFCS Verification Form, or the intake report from child or adult protective

CRIME INFORMATION

services with your application.

Location of Crime (City and State)

Date of Crime (MM/DD/YY)

Date Crime Reported (MM/DD/YY)

Agency Crime Reported To

Report/Law Enforcement Agency Case Number

Officer/Investigator Name

 Yes  No

Did the incident or alleged incident occur while the victim was in state custody (e.g. DFCS, APS, etc.)?

If yes, was the victim in state custody due to the victimization for which you are seeking reimbursement?  Yes  No

SECTION 4.

In this section, please provide information about the forensic interview.

FORENSIC INTERVIEW INFORMATION

Name of Facility

Date of Forensic Interview (MM/DD/YY)

Length of Interview

HR: MINS

Street Address (City, State, Zip Code)

Facility Phone Number

Has the Forensic Interviewer Funding Certification Document been submitted within the past year?

 Yes  No

SECTION 5.

In this section, please indicate the facility or individual who should receive payment and

REMIT TO

claim updates.

Name of Facility or Individual

FEI Number or Social Security Number

Street Address (City, State, Zip Code)

Communication Preference for claim updates?

Phone Number

Email Address

 Email  Mail

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Forensic Interview Form Page 2

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