Form JD-VS-34 "Reimbursement Child Forensic Interview" - Connecticut

What Is Form JD-VS-34?

This is a legal form that was released by the Connecticut Judicial Branch - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Connecticut Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-VS-34 by clicking the link below or browse more documents and templates provided by the Connecticut Judicial Branch.

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Download Form JD-VS-34 "Reimbursement Child Forensic Interview" - Connecticut

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REIMBURSEMENT
STATE OF CONNECTICUT
OFFICE OF VICTIM SERVICES
CHILD FORENSIC INTERVIEW
JUDICIAL BRANCH
JD-VS-34 Rev. 3-18
C.G.S. § 19a-112a
www.jud.ct.gov/crimevictim/
Instructions
Providers or examiners working with a
To apply for reimbursement, complete all sections
multidisciplinary team, or a child advocacy
of this form. Mail the completed form to:
Office of Victim Services
center, or both, may be reimbursed $250 for
a forensic interview of a child victim of sexual
Attn: Forensic Interview Reimbursement
assault or abuse.
225 Spring Street
Wethersfield CT 06109
Section 1 — Victim Information
Name of victim/patient
Date of birth
Account or record number
If 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 — Services Provided
Name and title of interviewer
Date of forensic interview
Is 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
Health care provider name
Date of referral/Forensic examination
Section 3 — Billing Information
Health care provider name
Telephone number
Tax identification number
Address
City
State
Zip
Section 4 — Signature Of Person Completing Form
Name and title of person completing form
Telephone number and email address
Date signed
Signature of person completing form
Print Form
Reset Form
REIMBURSEMENT
STATE OF CONNECTICUT
OFFICE OF VICTIM SERVICES
CHILD FORENSIC INTERVIEW
JUDICIAL BRANCH
JD-VS-34 Rev. 3-18
C.G.S. § 19a-112a
www.jud.ct.gov/crimevictim/
Instructions
Providers or examiners working with a
To apply for reimbursement, complete all sections
multidisciplinary team, or a child advocacy
of this form. Mail the completed form to:
Office of Victim Services
center, or both, may be reimbursed $250 for
a forensic interview of a child victim of sexual
Attn: Forensic Interview Reimbursement
assault or abuse.
225 Spring Street
Wethersfield CT 06109
Section 1 — Victim Information
Name of victim/patient
Date of birth
Account or record number
If 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 — Services Provided
Name and title of interviewer
Date of forensic interview
Is 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
Health care provider name
Date of referral/Forensic examination
Section 3 — Billing Information
Health care provider name
Telephone number
Tax identification number
Address
City
State
Zip
Section 4 — Signature Of Person Completing Form
Name and title of person completing form
Telephone number and email address
Date signed
Signature of person completing form
Print Form
Reset Form