Elder Abuse Initial Case Assessment Form
Client Information
Name
Date of Birth
Gender
Male
Female
Other
Address
Phone
Referral Details
Date of Referral
Referrer Name/Agency
Relationship to Client
Alleged Abuse Details
Type of Abuse
Physical
Emotional
Financial
Sexual
Neglect
Other
Date / Time of Abuse
Describe the Alleged Abuse
Alleged Perpetrator(s) Information
Name
Relationship to Client
Contact Information
Client's Current Status
Physical and Mental Condition
Is the client safe now?
Yes
No
Unknown
Immediate Action Taken
Details
Additional Notes / Observations
Completed By
Date