Online Intake Form
National Grooming Prevention Hotline
SECTION1: INTAKE DETAILS
From Completed By
First Name
Last Name
Section 2: REPORTING PERSON (IF DIFFERENT FROM VICTIM)
Name
First Name
Last Name
Relationship to Individual
Parent
Guardian
Relative
Teacher
Friend
Self
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
Phone
Email
Text
SECTION 3: INDIVIDUAL OF CONCERN (POTENTIAL TARGET OF GROOMING)
Name
First Name
Last Name
Age
Gender
Select which Applies
Minor
Vulnerable adult
Name of Primary Caregiver/Guardian (if minor)
SECTION 4: ALLEGED PERSON OF CONCERN (If known)
Name
First Name
Last Name
Approximate Age
Relationship to Victime (if any)
Position of Trust or Authority?
Yes
No
Unknown
SECTION 5: INITIAL CONCERNS
Document Concerns Here:
How did you become aware of these Concern?
SECTION 6: GROOMING INDICATORS (check all that apply)
Indicators
Excessive attention, gifts, money or favors
secretive communication (hidden apps, deleted messages)
Encouragining secrecy from parents/caregivers
isolation from family or friends
Normalizing sexual topics or jokes
Sexualized comments, photos, or videos
Requests for images, videos, or live interaction
Manipulation, guilt, or emotional dependence
Threats, cocercion, or intimidation
Offering protection, love, housing or financial help
Desensitization to boundaries
Escalation of contact or intensity
Online gaming, livestreaming, or socialmedia contact
Sudden behavior or mood changes
Other
** If OTHER, write the information here
SECTION 7: COMMUNICATION DETAILS
Type of Contact Potential Groomer is using
Text
Phone
Social media
Gaming platform
Email
In-person
Other
List games or social media used
SECTION 8: SAFETY CONCERNS
Select what applies
Immediate danger suspected
Threats made
Requests for in-person meeting
Requests for potential victium to meet in person
Any exchange of money or goods
Any sexual images/videos requested
Any sexual images/videos sent by victim
No immediate safety concerns by the reporting person
SECTION 9: DISCLOSURES (If any)
Has the individual (potentially being groomed) disclosed to you that there has been any sexual contact, request for pictures or videos. If 'YES' please describe more in detail in the box below.
Yes
No
Unsure
Type option 4
**If YES above - write the details here
SECTION 10: ACTIONS TAKEN
1. Make sure the victim is safe and not left alone. 2. Call the police. 3. Do not delete any text messages or other forms of potential evidence, such as images, usernames, profile links, email addresses, or videos. 3. Do not interrogate the victim but do write down anything the victim shares. 4. Do not place blame or shame the victim - reassure: "You did the right thing by telling someone". 5. Contact the Cyber tip line at www.cybertip.org. 6. If the victim is an adult, call the police to make a report
I Understand these steps.
Check List
Remove the victim from danger
Preserve evidence
Make law enforcement report
Remove electronic devices
Do not confront the potential groomer
Do not promise confidentialty you cannot keep
Do not minimize situation because it hasn't turned physical yet
Develop a safety plan (we will email them one)
Contact trauma informed counseling
SECTION 11: ADDITIONAL NOTES
Write any additional notes here
Submit
Date
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