NGPH Intake Form

Online Intake Form

National Grooming Prevention Hotline
SECTION1: INTAKE DETAILS
From Completed By

First NameLast Name
Section 2: REPORTING PERSON (IF DIFFERENT FROM VICTIM)
Name

First NameLast Name
Relationship to Individual

ParentGuardianRelativeTeacherFriendSelfOther
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Method of Contact

PhoneEmailText
SECTION 3: INDIVIDUAL OF CONCERN (POTENTIAL TARGET OF GROOMING)
Name

First NameLast Name
Age
Gender
Select which Applies

MinorVulnerable adult
Name of Primary Caregiver/Guardian (if minor)
SECTION 4: ALLEGED PERSON OF CONCERN (If known)
Name

First NameLast Name
Approximate Age
Relationship to Victime (if any)
Position of Trust or Authority?

YesNoUnknown
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 favorssecretive communication (hidden apps, deleted messages)Encouragining secrecy from parents/caregiversisolation from family or friendsNormalizing sexual topics or jokesSexualized comments, photos, or videosRequests for images, videos, or live interactionManipulation, guilt, or emotional dependenceThreats, cocercion, or intimidationOffering protection, love, housing or financial helpDesensitization to boundariesEscalation of contact or intensityOnline gaming, livestreaming, or socialmedia contactSudden behavior or mood changesOther
** If OTHER, write the information here
SECTION 7: COMMUNICATION DETAILS
Type of Contact Potential Groomer is using

TextPhoneSocial mediaGaming platformEmailIn-personOther
List games or social media used
SECTION 8: SAFETY CONCERNS
Select what applies

Immediate danger suspectedThreats madeRequests for in-person meetingRequests for potential victium to meet in personAny exchange of money or goodsAny sexual images/videos requestedAny sexual images/videos sent by victimNo 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.

YesNoUnsureType 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 dangerPreserve evidenceMake law enforcement reportRemove electronic devicesDo not confront the potential groomerDo not promise confidentialty you cannot keepDo not minimize situation because it hasn't turned physical yetDevelop a safety plan (we will email them one)Contact trauma informed counseling
SECTION 11: ADDITIONAL NOTES
Write any additional notes here
Date

Online Intake Form

SECTION1: INTAKE DETAILS

Section 2: REPORTING PERSON (IF DIFFERENT FROM VICTIM)

SECTION 3: INDIVIDUAL OF CONCERN (POTENTIAL TARGET OF GROOMING)

SECTION 4: ALLEGED PERSON OF CONCERN (If known)

SECTION 5: INITIAL CONCERNS

SECTION 6: GROOMING INDICATORS (check all that apply)

SECTION 7: COMMUNICATION DETAILS

SECTION 8: SAFETY CONCERNS

SECTION 9: DISCLOSURES (If any)

SECTION 10: ACTIONS TAKEN

SECTION 11: ADDITIONAL NOTES