REIMBURSEMENT CHILD FORENSIC INTERVIEW. Connecticut Bar Examining Committee Additional Response Page - Form 2S 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1 — Victim Information. Enter the name of the victim/patient, their date of birth, and account or record number. If applicable, indicate whether the victim is an adult with a developmental delay or functional impairment by selecting 'Yes' or 'No'. Provide an explanation if 'Yes' is selected.
3. Move to Section 2 — Services Provided. Fill in the name and title of the interviewer along with the date of the forensic interview. Specify if this is a reopened case by selecting 'Yes' or 'No', and mark whether it pertains to a new incident or different perpetrator.
4. Indicate if there was a referral for a forensic medical examination by selecting 'Referral' or 'Forensic examination completed'. Include the date of referral/examination and health care/provider name.
5. Proceed to Section 3 — Billing Information. Enter the health care/provider name, telephone number, address, city, state, and zip code.
6. Finally, complete Section 4 — Signature Of Person Completing Form. Provide your name, title, telephone number, email address, signature, and date signed.

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