Intake Form

Thank you for dedicating your time to fill out the referral form for Milwaukee County's Adult Protective Services (APS).

APS Serves individuals 60+ years old as well as those aged 18+ with disabilities that maybe impacted by abuse, neglect or exploitation. We are eager to extend our support. As you proceed with completing the form, we will request your contact information. However, if you would prefer to make an anonymous referral, please call this number 414-289-6874. To begin the process, please click on "Start" below.

Adult Protective Services Intake Form
The individual I am seeking help for is experiencing a Mental Health Crisis.The individual I am seeking help for is experiencing Homelessness.The individual I am seeking help for is in extreme danger at this moment.The individual I am seeking help for is experiencing Domestic AbuseThe individual I am seeking help for is experiencing abuse while living in a Long Term care FacilityNone of these apply.

Adult Protective Services Intake Form
YesNo
I want to provide an update on the previous referralI would like to check the status of my previous referral
Thank you for taking the time update your previous referral, we will now ask you share a few details so our team can connect your update to the appropriate referral
First name*
Last name
Phone number

Area CodePhone Number
Email
example@example.com
Please share the contact information for the individual you made the initial referral about
First name*
Last name*
Phone number

Area CodePhone Number
Email
example@example.com
Please provide your update on this Referral
YesNo
The individual is 17 years old or youngerThe individual is between the ages of 18-59The individual is 60+ years old
YesNoI'm not sure
Contact Info: Please share YOUR contact information
First name*
Last name*
Phone number*

Area CodePhone Number
Email
example@example.com
Information about the Individual of Concern

Please enter the contact information for the of individual you are concerned about:
First name*
Last name*
Phone number

Area CodePhone Number
Email
example@example.com
Please enter their date of birth:

DayMonthYear
Please enter the address for the individual you are concerned about*

Address

Address line 2

City/TownState/Region/Province

Zip/Post Code
Please select the race for the individual you are making a referral for *
Please select the gender for the individual you are making a referral for *
Physical Abuse: includes assaults like hitting, punching, and pushing. In some states, it can also involve over-medicating adults to make them sleep or preventing them from leaving home.Sexual Abuse: It typically involves sexual contact or penetration. Some states include actions like photographing a victim nude or forcing them to watch pornography. Forced prostitution is considered sexual abuse in some areas. Consent standards and perpetrator custody requirements vary by state.Financial Exploitation:misusing an adult's assets, possibly without consent, through coercion or manipulation, with state variations on whether a trusted relationship is required for APS investigation, and potential cross-reporting between agencies. APS may open self-neglect cases when victims are unable to meet their needs due to scams or thefts.Caregiver Neglect: Failure to provide expected care, such as nutrition, shelter, healthcare, or supervision, with state definitions of caregivers varying. For instance, adult children's status as caregivers can be unclear, depending on state requirements regarding payment or assumed responsibility.Self Neglect:Occurs when older adults or those with disabilities fail to meet their essential needs, endangering their health and well-being. APS generally accepts reports if the individual meets the state's client criteria, but situations may persist if the individual refuses APS services due to decision-making capacity.
How long have you suspected this type of Abuse to be taking place for {name1}?*
When did the concerning situation that prompted you to make this referral occur? (If you know the specific date please enter it, otherwise please share the timeframe)*
YesNoI'm not sure
Please provide more detail as to which interventions have taken place. Please share when interventions took place and what the outcomes were for each.
Please share any additional details that can help us be more informed about your concerns
YesNo
Who is the safest person to call to follow-up on this matter?*
What is the best number to call?*

Country CodeArea CodePhone Number
Is there a specific time to call?
Should be Empty:

Thank you for dedicating your time to fill out the referral form for Milwaukee County's Adult Protective Services (APS).

Adult Protective Services Intake Form

Adult Protective Services Intake Form

Contact Info: Please share YOUR contact information

Information about the Individual of Concern