Alamance County Electronic APS Report
If this is an Emergency. Call 336-570-6777 and ask for the On Call Social Worker
Name: Can be anonymous.
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Gender
*
Male
Female
Other
Others in Residence
What happened to make you call today?
How has the adult’s physical/mental health and functioning declined or changed?
Is the adult possibly in immediate danger of death? If yes, describe the danger.
Is the adult at risk of irreparable harm? If yes, describe the danger.
Describe the adult’s physical and/or mental diagnosis
Has any one assumed the responsibility for the adult’s day-to-day well-being?
Yes
No
Does someone help with the decision-making?
Yes
No
Is someone managing the adult’s finances?
Yes
No
Are there any environmental or safety issues that the worker should be aware of? (If yes, please explain)
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