Adult Protective Services

* The report I am submitting does not require an emergency response

Public Intake

Please note fields marked * are required.

Client Information

*First Name:

Middle Name:

*Last Name:

* DOB:

OR Age:

Exact Age Unknown

SSN: ###-##-####

Language:

Speaks English

Ethnicity:

Race:

Gender:

Sexual Orientation:

Living Arrangements:

Address:

City:

Zip Code:

Primary Phone:

Home Phone :

Work Phone :

Cell/Other Phone:

Current Location: (if different from address)

Physical/Mental Impairmants (if under 65)

Suspected Abuser #1

First Name:

*Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Address:

Lives with client

SSN ###-##-####

City:

State:

Zip Code:

Primary Phone:

Home Phone:

Work Phone:

Cell/Other Phone:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Suspected Abuser # 2

First Name:

*Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Address:

Lives with client

SSN ###-##-####

City:

State:

Zip Code:

Primary Phone:

Home Phone:

Work Phone :

Cell/Other Phone:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Suspected Abuser # 3

First Name:

*Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Address:

Lives with client

SSN ###-##-####

Primary Phone:

Home Phone:

Work Phone:

Cell/Other Phone:

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Reporting Party

*First Name:

*Last Name:

Gender:

Ethnicity:

Race:

*Collateral Type:

Resource Type:

Relation to Victim:

Email:

Work Place:

Occupation:

Address:

Lives with client

City:

State:

Zip Code:

Primary Phone:

Home Phone:

Work Phone:

Other Phone:

Best time of day to reach you (25 chars max):

Incident Information

Date of incident:

Time of incident:

*Address:

Use client address

Phone

City:

Zip Code:

Incident Occurred At:

Incident Other:

Select the institution reporting (if applicable):

Situation Reported

What happened today that led you to make this report? (Observations, beliefs, statements made by victim) (2000 characters max) *

Does the Suspected Abuser still have access to the victim?

Yes

If Yes, explain. Provide any known time frame (2 days, 1 week, ongoing etc.) (500 characters max)

If the Alleged Victim is under 65, please describe their cognitive and/or physical limitations. (Do they need a caregiver to meet their basic daily needs? Are they wheelchair dependent? What current third party assistance are you aware of for this person?) (500 characters max)

Is there a potential danger to the investigating worker, or other problem with access? (guns, animals, recent violence etc.)

Yes

If yes please specify: (500 characters max)

Other Persons Believed To Have Knowledge Of Abuse Family Member Or Other Person Responsible For Victim's Care. (If unknown, list contact person) Add Person

First Name:

Last Name:

DOB:

SSN: ###-##-####

Gender:

Race:

Collateral Type:

Resource Type:

Relation to Victim:

Address:

Lives with client

City:

State:

Zip Code:

Primary Phone:

Home Phone:

Work Phone:

Cell/Other Phone:

Other Agency Information (Please answer if law enforcement has been contacted.) Add Law Enforcement

Agency

First Name

Last Name

Phone Number

Date

Additional Information

Please provide any other information that would help up investigate:

* I understand that if I do not see a confirmation message my report has NOT been submitted and I must check for errors or incomplete entries on the form.

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