Child Abuse Reporting Form

Child & Family Services

    For any child who is currently in danger of serious injury, or is suspected to be currently in danger of serious injury, please stop now and call law enforcement.

    Are any of the below questions true regarding the situation you are reporting?
    If so, please call 1-855-323-3237 and do not use the online reporting form.

    • Has the the child’s parent/caregiver said they may cause serious harm to the child?

    • Does the child have visible injuries from abuse or neglect?

    • Did the child tell you they are being abused or neglected, and they are afraid to go home?

    • Has the child been admitted to a hospital due to abuse or neglect?

    • Is there a report of sexual abuse or serious physical abuse and the alleged perpetrator has access to the child?

    • Is there an active meth lab in the home?

    • Is a newborn having adverse effects due to substance abuse by the mother during pregnancy?

    • Is there a suspicious or unexplained death of a child in the home?

    • Does the child need emergency treatment (medical or psychological) and the parents/caregiver are unavailable or refusing to get treatment?

    • Is there no caregiver available for the child and they are unable to care for themselves, or they are in immediate danger due to no protection?

    • Has law enforcement or a physician taken protective custody of a child?

    • Are you a member of law enforcement and need assistance at the scene?

    Do any of the above questions apply to your concerns?
    YesNo

    Please stop now and contact us at 1-855-323-3237 for immediate assistance, or call law enforcement.

    Your Information

    As a reporting professional, your information is critical for our assessment of the situation and our follow up with you. Any information you provide will be kept confidential, as is required by state law. If you prefer not to share this information, we ask that you call our hotline (855-323-3237) directly.

    First Name*

    Last Name*

    Phone*

    Relationship to Alleged Victim

    Agency/organization you are associated with (if applicable)

    Email*

    Address

    Incident Details

    What happened?*

    Where did the incident occur? (address if known)

    When did the incident occur? Is it ongoing? (if known)

    Has the alleged victim seen a medical or mental health provider related to the abuse/neglect?
    YesNoUnknown

    Is the alleged victim in foster care, or were they at the time of the incident?
    YesNoUnknown

    Alleged Victim

    First Name (or other way to identify)*

    Last Name

    Age (if known)

    DOB (if known or estimated)

    Gender

    Disabilities or special needs (if known)

    Address of residence (or other way to locate)*

    School/Daycare (if known)

    Please add names, ages or date of birth of siblings in the home (if known)

    Are there any other alleged victims you would like to report?
    YesNo

    Alleged Victim 2

    First Name

    Last Name

    Age (if known)

    Date of birth (if known)

    Gender

    Disabilities or special needs (if known)

    Address of residence (or other way to locate)*

    School/Daycare (if known)

    Please add names, ages or date of birth of siblings in the home (if known)

    Parent/Caregiver

    First Name

    Last Name

    Age (if known)

    Date of birth (if known)

    Gender

    Address of residence (if known)

    Phone (if known)

    Employment (if known)

    Add another parent/caregiver?
    YesNo

    Parent/Caregiver 2

    First Name

    Last Name

    Age (if known)

    Date of birth (if known)

    Gender

    Address of residence (if known)

    Phone (if known)

    Employment (if known)

    Is the person alleged to have caused abuse/neglect a parent/caregiver listed above?
    YesNo

    PERSON ALLEGED TO HAVE CAUSED ABUSE/NEGLECT

    First Name

    Last Name

    Age (if known)

    DOB (if known or estimated)

    Gender

    Address (if known)

    Phone (if known)

    Employment (if known)

    Relationship to Alleged Victim(s)

    Does the person alleged to have caused abuse/neglect still have access to the victim?*
    YesNoUnknown

    Add another alleged perpetrator?
    YesNo

    PERSON ALLEGED TO HAVE CAUSED ABUSE/NEGLECT 2

    Is the alleged perpetrator the parent, guardian, or caretaker of the alleged victim?
    YesNo

    First Name

    Last Name

    Age (if known)

    Date of birth (if known)

    Gender

    Address of residence (if known)

    Phone (if known)

    Employment (if known)

    Relationship to Alleged Victim(s)

    Does the person alleged to have caused abuse/neglect still have access to the victim?*
    YesNoUnknown