IM SAFE CAC Referral Form

Township/City/Village of Incident

Primary Language *

Who is bringing the child to the CAC?

Child's Full Legal Name *

Suspect's Gender *

Any special considerations for the child we need to be aware of?

Legal Guardian(s) Name(s) *

Child's Gender *

Referrals for forensic interviews are only accepted from Law Enforcement and the Department of Health and Human Services. If you are with one of these agencies, please fill out the form below to the best of your ability and we will contact you shortly with available dates and times.

If you need to report suspected child abuse or neglect, call DHHS Centralized Intake at 1-855-444-3911

Any questions, please contact the Intake Coordinator at imsafecac@gmail.com, or (616) 225-7267.

Legal Guardian(s) Contact Information *

Suspect's Address

Suspect's Date of Birth

Referring Officer or DHHS Caseworker

Suspect's Full Legal Name *

Type of Abuse *

Sexual Abuse

Physical Abuse

Human Trafficking

Child Sexually Abusive Activity

LE Case # *

Suspect's Race *

Note: If a CSC occurred within the past 120 hours, a SANE exam should be completed immediately. Contact the

YWCA (616-459-4681).

Medical Referral Made

Seen in Emergency Room prior to FI *

DHHS Caseworker Email

LE Email *

County of Incident/Child's Home *