Child Protective Services (CPS) Intake Form
Reporter Information
Name
Affiliation/Agency
Phone Number
Email
Relationship to Child
Child Information
Name
Date of Birth
Address
Phone Number
School/Daycare
Parent/Guardian Information
Name
Relationship to Child
Address
Phone Number
Abuse/Neglect Information
Type of Abuse/Neglect
Physical
Sexual
Emotional
Neglect
Other
Description of Incident(s)
Approximate Date/Time of Incident
Injuries Observed
Additional Information
Other children in the home (names & ages)
Other relevant details