Child Protective Services Intake Form
Referral Date
Referring Party Information
Name
Relationship to Child
Contact Number
Child Information
Child Name
Age
Gender
Male
Female
Other
Address
School/Daycare
Parent/Guardian Information
Name
Relationship
Contact Number
Address
Allegation Details
Type of Abuse/Suspected Harm
Physical
Neglect
Sexual
Emotional
Other
Other Household Members
Immediate Safety Concerns
Additional Notes