Adult Protective Services

By completing this Web Intake you have fulfilled your verbal AND written mandate to report. If you also speak to an APS intake Social Worker, please inform them you have completed the Web Intake to avoid duplication of this Report.

Emergency responses must be submitted by phone. Please call Sonoma County APS hotline: 707-565-5940 or toll free, 800-667-0404.

* The report I am submitting does not require an emergency response

Public Intake

Submit

Please note fields marked * are required.

Suspected Abuser #1

First Name:

*Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone :

Work Phone :

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Suspected Abuser # 2

First Name:

*Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone:

Work Phone :

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Suspected Abuser # 3

First Name:

*Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone:

Work Phone:

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Reporting Party

*First Name:

*Last Name:

Gender:

Ethnicity:

Race:

*Collateral Type:

Resource Type:

Relation to Victim:

*Email:

*Work Place:

*Occupation:

Home Phone:

*Work Phone:

Other Phone:

*Address:

Lives with client

City:

State:

Zip Code:

Best time of day to reach you (25 chars max):

Incident Information

Date of incident:

Time of incident:

*Address:

Use client address

City:

Zip Code:

Incident Occurred At:

Incident Other:

Select the institution reporting (if applicable):

Situation Report

What happened today that led you to make this report? (Observations, beliefs, statements made by victim) (2000 characters max) *

Does the Suspected Abuser still have access to the victim?

Yes

If Yes, explain. Provide any known time frame (2 days, 1 week, ongoing etc.) (500 characters max)

If the Alleged Victim is under 60, please describe their cognitive and/or physical limitations. (Do they need a caregiver to meet their basic daily needs? Are they wheelchair dependent? What current third party assistance are you aware of for this person?) (500 characters max)

Is there a potential danger to the investigating worker, or other problem with access? (guns, animals, recent violence etc.)

Yes

If yes please specify: (500 characters max)

Other Persons Believed To Have Knowledge Of Abuse Family Member Or Other Person Responsible For Victim's Care. (If unknown, list contact person) Add Person

First Name:

Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Email:

Work Place:

Occupation:

Home Phone:

Work Phone:

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

Written Report (Enter information about the agencies receiving this report. Not required if only reporting to APS.) Add Agency

Agency

Contact First Name

Contact Last Name

Mailed

Address

Date

Faxed

Fax Number

Date

Agency

Contact First Name

Contact Last Name

Mailed

Address

Date

Faxed

Fax Number

Date

Agency

Contact First Name

Contact Last Name

Mailed

Address

Date

Faxed

Fax Number

Date

* I understand that if I do not see a confirmation message my report has NOT been submitted and I must check for errors or incomplete entries on the form.

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a. High Disaster Vulnerability	e. Developmentally Disabled	h. Mental Illness
b. Moderate Disaster Vulnerability	f. Chronic Health Problems	i. Unknown
c. Low Disaster Vulnerability	g. HST	Intellectual disability
d. Activities of Daily Living