Child Protective Services
Crisis Intervention Report
Reporter Information
Name
Agency/Relationship
Contact Number
Date & Time of Report
Child Information
Name
Date of Birth
Gender
Address
Parent/Guardian Information
Name
Relationship to Child
Contact Number
Address (if different)
Nature of Crisis
Description of Crisis Situation
Immediate Danger to Child?
Yes
No
Unknown
Actions Taken
Steps Taken Prior to Report
Other Agencies Involved
Assessment & Recommendations
Assessment/Observations
Recommendations or Referrals
For Office Use Only
Received By
Date Received
Time Received
Assigned To