Ellis County Children's Advocacy Center

Child's Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Requested Services

Family Advocacy Services

Therapy Services

MDT Staffing

Child(ren) previously seen at ECCAC

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Name of Alleged Perpetrator

First Name

Last Name

Type of Allegation

Sexual

Physical

Other

Referred By (Name)

First Name

Last Name

Referred By Phone

(###)

###

####