Child Protective Services Intake Form
Reporter Name
Reporter Role/Relation
Reporter Contact Information
Child Name
Child Date of Birth
Child Address
Parent/Guardian Name(s)
Parent/Guardian Contact
Type of Allegation
Neglect
Physical Abuse
Sexual Abuse
Emotional Abuse
Other
Details of Allegation
Is the Child in Imminent Danger?
Yes
No
Unknown
Other Household Members (Name & Relation)
Additional Notes / Observations