Suspected Child Abuse or Neglect Referral

Child(ren)'s Name(s)

Child(ren)'s Date of Birth and/or Age

School or Day Care Child(ren) Attend(s)

Parent(s)/Guardian Name(s)

Parent(s)/Guardian Telephone Number(s)

Address

City

State

Zip Code

Is parent/guardian aware of report?

NoYes

Is child aware of report?

NoYes

Last known incident of suspected abuse/neglect and date

Describe concerns/reasons for referral

Did you place a phone call to Social Services Intake?

NoYes

Who did you speak with?

Date and time you called

Alleged Perpetrator Information

First Name

Last Name

Relationship to child

Phone Number

Address

City

State

Zip Code

Reporter's Information

First Name

Last Name

Phone Number

Organization

Business Address

City

State

Zip Code

Do you want to be notified of the screening decision?

NoYes

Are you a mandated reporter?

NoYes

Additional Information

Did you witness, or observe, these concerns?

NoYes

If yes, explain. If no, how did you obtain the information?

What are some positives and/or who are some supports for this family?

Are there safety concerns for the children or for someone who may visit the home?

NoYes

Please include any information about the safety concerns.

What convinced you to call or take action today?

Has something like this happened before, or is there similar history?

NoYes

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