Reimbursement Child Forensic Interview {JD-VS-34}

REIMBURSEMENT CHILD FORENSIC INTERVIEW JD-VS-34 Rev. 3-18 C.G.S. 247 19a-112aSTATE OF CONNECTICUT OFFICE OF VICTIM SERVICES JUDICIAL BRANCH www.jud.ct.gov/crimevictim/ InstructionsProviders or examiners working with a multidisciplinary team, or a child advocacy center, or both, may be reimbursed $250 for a forensic interview of a child victim of sexual assault or abuse.To apply for reimbursement, complete all sections of this form. Mail the completed form to: Office of Victim Services Attn: Forensic Interview Reimbursement 225 Spring Street Wethersfield CT 06109Section 1 227 Victim Information Name of victim/patient Date of birth Account or record numberIf the victim is an adult (over 17 years old), does the victim have a developmental delay or other functional impairment? Yes No If yes, explain:Section 2 227 Services Provided Name and title of interviewer Date of forensic interviewIs this a reopened case? Yes No If yes, "x" if this is a New incident Different perpetrator Evaluation for suspected sexual assault or abuse Other: Was the victim referred for or did the victim have a forensic medical physical examination? Referral Forensic examination completed No Date of referral/Forensic examination Health care provider nameSection 3 227 Billing Information Health care provider name Telephone number Tax identification number Address City State ZipSection 4 227 Signature Of Person Completing Form Name and title of person completing form Telephone number and email address Signature of person completing form Date signed American LegalNet, Inc. www.FormsWorkFlow.com