Referral Intake Form
Please complete all required sections to facilitate case intake and review. Fields marked as required must be filled before submission.
Role Information
Provide your role and contact details.
Role
*
DSS Investigator
Law Enforcement Investigator
Phone
*
Enter a direct number where you can be reached if clarification is needed.
Format: (000) 000-0000.
Email
*
Enter your work email address for confirmation and follow-up if needed.
Summary of Incident
Describe the incident and related notifications.
Incident Summary
*
Provide a clear, factual overview of the incident, including relevant context needed for case intake.
Date Law Enforcement Was Notified
-
Month
-
Day
Year
Enter the date law enforcement was first informed of this incident.
Who Reported it to Law Enforcement?
*
Indicate who initially reported the incident to law enforcement.
Child Information
Details about the child involved in the incident.
Child Name
*
Enter the child’s full legal name.
Child Date of Birth
*
-
Month
-
Day
Year
Enter the child’s date of birth. If unknown, use best available information.
Child Sex
*
Male
Female
Relationship to Alleged Perpetrator
*
Please Select
Parent / Step-Parent / Guardian
Sibling / Other Child in Home
Other Family Member
Family Friend / Neighbor
Caregiver / Babysitter
Teacher / School Staff
Coach / Youth Program Staff
Religious Leader / Clergy
Healthcare or Service Professional
Peer / Friend
Stranger
Unknown / Not Disclosed
Select the relationship that best describes the alleged perpetrator’s connection to the child.
Last Known Contact with Perpetrator
-
Month
-
Day
Year
Enter the most recent known date of contact. If unknown, leave blank.
Parent / Caregiver Information
Information about the child's primary caregiver.
Primary Caregiver
*
Guardian
Parent
Caregiver Name
*
Enter the primary caregiver’s full name.
Caregiver Phone
*
Enter a reliable contact number for the caregiver.
Format: (000) 000-0000.
Caregiver Primary Language
*
English
Non-English
Has Legal Custody?
*
Yes
No
Unknown
Alleged Perpetrator Information
Provide information about the alleged perpetrator, if known.
Alleged Perpetrator Name
*
Enter the alleged perpetrator’s name, if known.
Alleged Perpetrator Address
*
Enter the last known address, if available.
Alleged Perpetrator Date of Birth
-
Month
-
Day
Year
Enter the date of birth, if known.
Is Alleged Perpetrator Under 18?
Under 18
Alleged Perpetrator Phone Number
Enter a contact number if known.
Format: (000) 000-0000.
Incident Details
Specific details about the incident and resulting actions.
Injury?
*
Yes
No
Type of Abuse
*
Sexual
Physical
Did the Child Go to the Hospital or See a Doctor?
*
Yes
No
Hospital/Doctor Name
*
Enter the name of the hospital or medical provider.
When did the child go to the Hospital/Doctor?
*
-
Month
-
Day
Year
Enter the date of the hospital visit.
Was a Sexual Assault Kit Performed?
*
Yes
No
Where Did the Incident Occur?
*
Describe the location where the incident took place.
When Did the Incident Occur?
*
-
Month
-
Day
Year
Enter the date of the incident. If exact date is unknown, use best estimate.
Scheduling Contact
Contact for scheduling services related to this referral.
Scheduling Contact Name
*
Enter the name of the person who should be contacted to schedule services.
Scheduling Contact Phone
*
Enter the best number to reach this contact.
Format: (000) 000-0000.
Scheduling Contact Primary Language
*
English
Non-English
Attachments
Upload supporting documents, if available.
Consent Form Upload
Upload a File
Drag and drop files here
Choose a file
Upload the completed consent form, if available.
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of
Police Report Upload
Upload a File
Drag and drop files here
Choose a file
Upload the police report or related documentation, if available.
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of
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