FAQs

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*Required Fields.

Reporter - (Your Name)

First: * Middle: Last: *
Gender: Male Female
Day Time Phone #: * Ext: Phone Type:* Select One Business Business Cell Residence Residence Cell
Night Time Phone #: * Ext: Phone Type:* Select One Business Business Cell Residence Residence Cell
Street: * Address Type: * Select One Business Residence
City: * State:* TX AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN UT VA VT WA WI WV WY Zip: County: * Select One Anderson Andrews Angelina Aransas Archer Armstrong Atascosa Austin Bailey Bandera Bastrop Baylor Bee Bell Bexar Blanco Borden Bosque Bowie Brazoria Brazos Brewster Briscoe Brooks Brown Burleson Burnet Caldwell Calhoun Callahan Cameron Camp Carson Cass Castro Chambers Cherokee Childress Clay Cochran Coke Coleman Collin Collingsworth Colorado Comal Comanche Concho Cooke Coryell Cottle Crane Crockett Crosby Culberson Dallam Dallas Dawson Deaf smith Delta Denton Dewitt Dickens Dimmit Donley Duval Eastland Ector Edwards Ellis El paso Erath Falls Fannin Fayette Fisher Floyd Foard Fort bend Franklin Freestone Frio Gaines Galveston Garza Gillespie Glasscock Goliad Gonzales Gray Grayson Gregg Grimes Guadalupe Hale Hall Hamilton Hansford Hardeman Hardin Harris Harrison Hartley Haskell Hays Hemphill Henderson Hidalgo Hill Hockley Hood Hopkins Houston Howard Hudspeth Hunt Hutchinson Irion Jack Jackson Jasper Jeff davis Jefferson Jim hogg Jim wells Johnson Jones Karnes Kaufman Kendall Kenedy Kent Kerr Kimble King Kinney Kleberg Knox Lamar Lamb Lampasas La salle Lavaca Lee Leon Liberty Limestone Lipscomb Live oak Llano Loving Lubbock Lynn Madison Marion Martin Mason Matagorda Maverick Mcculloch Mclennan Mcmullen Medina Menard Midland Milam Mills Mitchell Montague Montgomery Moore Morris Motley Nacogdoches Navarro Newton Nolan Nueces Ochiltree Oldham Orange Palo pinto Panola Parker Parmer Pecos Polk Potter Presidio Rains Randall Reagan Real Red river Reeves Refugio Roberts Robertson Rockwall Runnels Rusk Sabine San augustine San jacinto San patricio San saba Schleicher Scurry Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Swisher Tarrant Taylor Terrell Terry Throckmorton Titus Tom green Travis Trinity Tyler Upshur Upton Uvalde Val verde Van zandt Victoria Walker Waller Ward Washington Webb Wharton Wheeler Wichita Wilbarger Willacy Williamson Wilson Winkler Wise Wood Yoakum Young Zapata Zavala Out of state -None-
Place of Employment:
Your relationship to the victim/client: * Select One Community Agency Attorney Aunt\Uncle Passer-by Cousin Clergy Court Daughter Day Care Fac./Prov. Doctor EMS\EMT Financial Institute Other Family member Friend Family Viol. Shelter Grandchild Grandparent Guardian Atty/Gua Ad Litem In-Law Option Institution Law Enforcement Medical Fac. Staff Mental Health Prof. Neighbor Niece\Nephew Nurse Other Shelter Parent Clnt's Paramour(APS) Par's Paramour Service Provider Psychlgst/Psychitrst Other St. Agency Sibling School Personnel FPS staff Son Spouse Therapist Unrel. Home mem. Victim Other Parole/Probation Officer
Days and times you can be reached? *

Client - The adult you are concerned about.

Additional Client - Other adult you are concerned about who lives in the home.

First: Middle: Last:
Age, if the age is unknown provide an approximate: DOB:
Gender : Male Female    SSN:
Primary Language: Select One English French German Polish Sign Spanish Vietnamese Other Other:
Race/Ethnicity: Select One Am Indian/AK Native Asian Black Hispanic Native Hawaiian/Pacif Isl Unable to Determine White Other:
Will the client require a translator? Yes No Unknown

Is the client disabled? Yes No Unknown
If yes, what is the client's disability?


Is the client able to care for self? Yes No Unknown
If no, please explain how the client is unable to care for self (ie: unable to bathe, clean or cook for self)
Does the client receive disability benefits? Yes No Unknown
If yes, what type of benefits does the client receive? Select One SSI SSD VA Worker's Compensation Long Term Disability Insurance Unknown
What is the amount of disability income the client receives? Unknown
Does the client receive any other types of income? Yes No Unknown
What amount:

Alleged Perpetrator - Person suspected to have Abused/Neglected/Exploited the Client.

First: Middle: Last:
Relationship to Client: Select One Absent Parent Precon.Adop.Par(CPS) Attorney Aunt/Uncle Board & Care (APS) Com.Cntr.Staff(APS) Cousin Daughter Day Care Fac./Prov. Doctor Financial Institute Other Family member Foster Parent Friend Grandchild Grandparent Guardian Atty/Gua Ad Litem HCS Staff (APS only) Institut. Contracted Institut. Pers/vol. Medical Fac. Staff Niece/Nephew Parent Clnt's Paramour(APS) Par's Paramour Service Provider Psychlgst/Psychitrst Sibling School Personnel Son Spouse Step-Sibling (CPS) Step-Parent Therapist Unreg. Fam. Hom(CPS) Unrel. Home mem. Unknown Other Parole/Probation Officer
Home Address:
City: State: TX AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN UT VA VT WA WI WV WY Zip: County: Select One Anderson Andrews Angelina Aransas Archer Armstrong Atascosa Austin Bailey Bandera Bastrop Baylor Bee Bell Bexar Blanco Borden Bosque Bowie Brazoria Brazos Brewster Briscoe Brooks Brown Burleson Burnet Caldwell Calhoun Callahan Cameron Camp Carson Cass Castro Chambers Cherokee Childress Clay Cochran Coke Coleman Collin Collingsworth Colorado Comal Comanche Concho Cooke Coryell Cottle Crane Crockett Crosby Culberson Dallam Dallas Dawson Deaf smith Delta Denton Dewitt Dickens Dimmit Donley Duval Eastland Ector Edwards Ellis El paso Erath Falls Fannin Fayette Fisher Floyd Foard Fort bend Franklin Freestone Frio Gaines Galveston Garza Gillespie Glasscock Goliad Gonzales Gray Grayson Gregg Grimes Guadalupe Hale Hall Hamilton Hansford Hardeman Hardin Harris Harrison Hartley Haskell Hays Hemphill Henderson Hidalgo Hill Hockley Hood Hopkins Houston Howard Hudspeth Hunt Hutchinson Irion Jack Jackson Jasper Jeff davis Jefferson Jim hogg Jim wells Johnson Jones Karnes Kaufman Kendall Kenedy Kent Kerr Kimble King Kinney Kleberg Knox Lamar Lamb Lampasas La salle Lavaca Lee Leon Liberty Limestone Lipscomb Live oak Llano Loving Lubbock Lynn Madison Marion Martin Mason Matagorda Maverick Mcculloch Mclennan Mcmullen Medina Menard Midland Milam Mills Mitchell Montague Montgomery Moore Morris Motley Nacogdoches Navarro Newton Nolan Nueces Ochiltree Oldham Orange Palo pinto Panola Parker Parmer Pecos Polk Potter Presidio Rains Randall Reagan Real Red river Reeves Refugio Roberts Robertson Rockwall Runnels Rusk Sabine San augustine San jacinto San patricio San saba Schleicher Scurry Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Swisher Tarrant Taylor Terrell Terry Throckmorton Titus Tom green Travis Trinity Tyler Upshur Upton Uvalde Val verde Van zandt Victoria Walker Waller Ward Washington Webb Wharton Wheeler Wichita Wilbarger Willacy Williamson Wilson Winkler Wise Wood Yoakum Young Zapata Zavala Out of state -None-
Day Time Phone #: Ext:
Night Time Phone #: Ext:
Age: DOB: Gender : Male Female
SSN:
Primary Language: Select One English French German Polish Sign Spanish Vietnamese Other Other:
Race/Ethnicity: Select One Am Indian/AK Native Asian Black Hispanic Native Hawaiian/Pacif Isl Unable to Determine White Other:
Is this person a caretaker? Yes No Unknown
If yes, is the caretaker paid for services? Yes No Unknown
If paid for services, who is the caretaker's employer?
When does this person have access to the client? (Frequency, duration?)

Other alleged perpetrators - Provide names and details below:

Others - Household members or facility residents.

First: Middle: Last:
Age: DOB: Gender : Male Female
Primary Language: Select One English French German Polish Sign Spanish Vietnamese Other Other:
Race/Ethnicity: Select One Am Indian/AK Native Asian Black Hispanic Native Hawaiian/Pacif Isl Unable to Determine White Other:
Caregiver: Yes No Unknown

First: Middle: Last:
Age: DOB: Gender : Male Female
Primary Language: Select One English French German Polish Sign Spanish Vietnamese Other Other:
Race/Ethnicity: Select One Am Indian/AK Native Asian Black Hispanic Native Hawaiian/Pacif Isl Unable to Determine White Other:
Caregiver: Yes No Unknown

First: Middle: Last:
Age: DOB: Gender : Male Female
Primary Language: Select One English French German Polish Sign Spanish Vietnamese Other Other:
Race/Ethnicity: Select One Am Indian/AK Native Asian Black Hispanic Native Hawaiian/Pacif Isl Unable to Determine White Other:
Caregiver: Yes No Unknown

Collaterals - Persons with knowledge of the Abuse/Neglect/Exploitation.

First: Middle: Last:
Day Time Phone #: Ext:
Night Time Phone #: Ext:
Relationship to client: Select One Community Agency Attorney Aunt\Uncle Passer-by Cousin Clergy Court Daughter Day Care Fac./Prov. Doctor EMS\EMT Financial Institute Other Family member Friend Family Viol. Shelter Grandchild Grandparent Guardian Atty/Gua Ad Litem In-Law Option Institution Law Enforcement Medical Fac. Staff Mental Health Prof. Neighbor Niece\Nephew Nurse Other Shelter Parent Clnt's Paramour(APS) Par's Paramour Service Provider Psychlgst/Psychitrst Other St. Agency Sibling School Personnel FPS staff Son Spouse Therapist Unrel. Home mem. Victim Other Parole/Probation Officer
Days and times you can be reached?

First: Middle: Last:
Day Time Phone #: Ext:
Night Time Phone #: Ext:
Relationship to client: Select One Community Agency Attorney Aunt\Uncle Passer-by Cousin Clergy Court Daughter Day Care Fac./Prov. Doctor EMS\EMT Financial Institute Other Family member Friend Family Viol. Shelter Grandchild Grandparent Guardian Atty/Gua Ad Litem In-Law Option Institution Law Enforcement Medical Fac. Staff Mental Health Prof. Neighbor Niece\Nephew Nurse Other Shelter Parent Clnt's Paramour(APS) Par's Paramour Service Provider Psychlgst/Psychitrst Other St. Agency Sibling School Personnel FPS staff Son Spouse Therapist Unrel. Home mem. Victim Other Parole/Probation Officer
Days and times you can be reached?

Please answer the following questions as fully as you are able:
(If you do not know the answer, please indicate this.)

Why do you suspect abuse, neglect or exploitation?

What happened?* What did the caretaker do to the client or fail to do for the client? What did the client fail to do for him/herself? Provide details of the situation such as dates/times of incidents, client's current physical, mental, emotional condition. Describe any injuries (bruises, marks, welts, location, size/dimension, color, etc) and or client's current mental/emotional state (suicidal, fearful, disoriented, angry, etc.)