Child Maltreatment Intake Form

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Basic Information

Date of Report:
Staff who took the report:

Is alleged Maltreatment alleged to be ongoing?

Yes No

Name of Reporter:

First name: Last name:

Contact Information for Reporter:

Phone: Format: 123-456-7890
Email:
Mailing Address:
City:
State:

Preffered Method of Contact:

Phone Email Mail No Preference Do Not Contact

Response Status

Is danger being reported as imminent?

Yes No

Was Law Enforcement forwarded this report?

Yes No

Description of incident/s

Date of alleged maltreatment:

Please describe the incident/s with as much detail as possible; include locations of maltreatment, if known.

Names and ages of children harmed, or present during harm. If there are more than 4, list in the description above.

First name: Last name: Age:
First name: Last name: Age:
First name: Last name: Age:
First name: Last name: Age:

Name/s of alleged offender/s:

First name: Last name: Relationship to child/ren:

First name: Last name: Relationship to child/ren:

Collateral & Support Contacts

List all professional and/or family collateral who may be able to corroborate the report. Provide any contact information if you know it.

ICWA/MIFPA Information

Federal and State Law require child protection agencies to inquiry if children involved are enrolled in and federally recognized Native American Tribes, are eligible for enrollment, or of Native American descent.

Learn More

Does the reporter have reason to believe that ICWA or MIFPA may apply to the child or children involved in the report?

Yes No

List anyone who may know more about the enrollment status of the children involved in the report. Include contact info.

Thank You For Your Report

Someone will be in touch with you within 48 hours.

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