Attachment B_Blank_PS Intake Script.pdf

APS Intake Form

Report

Report Date: ____________________ Report Time:____________________

Report Method: (check one)

Telephone Email Fax Walk In

Web Written

Intake Worker: _____________________

Confidential/Restricted

Reporter Information Anonymous Report

Last Name___________________ Middle___ First Name____________________

Reporter Employer________________________________________________________

Street___________________________________________________________________

Street 2__________________________________________________________________

City___________________ State ___________________ Zip_____________

Home Phone_______________ Work Phone______________ Work Extension_____

Mobile Phone_______________________ Email Address________________________

Gender: Male Female Date of Birth_________________________

Reporter Legal Status:

Conservator Manages Own Legal/Financial Durable Power of Attorney Power of Attorney Guardian Rep. Payee Health Care Proxy Trustee

Relationship to Alleged Victim:

Advocate Daughter In-Law Other Family Step Brother

Power of Attorney

Dentist Landlord Other Professional

Step Sister

Aunt Doctor Lawyer Parent Step Parent

Bank Domestic

Partner

Law

Enforcement

Self Teacher

Brother Elected

Official

Legal

Guardian

Sibling Uncle

Caregiver Friend Neighbors Sister Personal Care

Attendant

Church Grandchild Non-Relative Social Worker Wife

Cousin Health/ Medical

Professional

Niece Son

Co-Worker Husband Nephew Spouse

Relationship to Incident:

Alleged Perpetrator Law Enforcement Primary Caretaker

Alleged Victim Non-Relative Service Provider

Biological Child Other Spouse

Collateral Contact Other Family Staff

Financial Institution Other Professional Unknown

Household Member Power of Attorney Witness

Reporter Mandated Type:

Coroner Mental Health Therapist PS Worker

Council on Aging Occupational Therapist Psychologist

EMT Other RN / LPN

Fire Services Physical Therapist Social Worker

HHA / (CNA) Physician/Physician

Assistant

Speech Therapist

Home Care Manager Police Officer

Homemaker Services Probation Officer

Best Time Contact:________________________________________________________

At Risk from Perpetrator: Yes No Unknown

Willingness to Help with Access: Yes No Unknown

Alleged Victim

Alias Last Name___________________ Alias First Name____________________

Employer__________________________________________________________

Directions to Victim’s Home: __________________________________________

SSN:_______________________________

Gender: Male Female

Multi Races:

American Indian and Alaska Native Some Other Race

Asian Unknown

Black or African American White

Native Hawaiian and Pacific Islander

Ethnicity:

Non Hispanic or Latino Hispanic or Latino Unknown

Date of Birth:______________________ Age at Intake:________________________

Age Estimated: ____________________ Date of Death________________________

Caregiver’s Legal Status:

Conservator Roger’s Guardian Durable Power of Attorney Social Security Recipient Guardian Trustee Health Care Proxy None

Power of Attorney Others

Rep. Payee

Alleged Victim’s Legal Status:

Alleged Victim Non-Relative Service Provider

Biological Child Other Spouse

Collateral Contact Other Family Psychologist

Attorney

Dentist Landlord Other Professional

Step Sister

Aunt Doctor Lawyer Parent Step Parent

Bank Domestic

Partner

Law

Enforcement

Self Teacher

Brother Elected

Official

Legal

Guardian

Sibling Uncle

Caregiver Friend Neighbors Sister Personal Care

Attendant

Church Grandchild Non-Relative Social Worker Wife

Cousin Health/ Medical

Professional

Currently At Residence? Yes No Unknown

If No, please specify the Alleged Victim’s temporary address:_______________________

Also, be sure to fill out the Alleged Victim’s Temporary Address workflow wizard in the

Harmony for APS system.

Marital Status:

Divorced Single Living Together Widowed Married Common-law Marriage Separated

Living Arrangements:

Alone With Relative Homeless With Spouse Licensed Facility Unknown Unlicensed Facility Other With Caregiver

Vulnerable Condition:

Elderly/Frail Physically Disabled

Mentally Disabled Unknown

Capacity to Consent:

Has Capacity Capacity in Question Lacks Capacity Unknown

If you answer Capacity in Question, the Capacity to Consent Screening work flow wizard will trigger. This screening should be completed by a PS Worker in the Harmony for

APS system.

If you mark Yes to this question, be sure to complete the At Risk from Perpetrator

Assessment workflow wizard in the Harmony for APS system.

Best Time Contact:________________________________________________________

Primary Language Spoken: ________________________________________________

Interpreter / Translator Needed?

Incident Incident Date: ___________________ Incident Time:___________________

Incident Location:

Alleged Victim Home Home Based Care

Licensed Assisted Living

State Institution

Community Care/Day Care Facility

Home of Other Nursing Facility Unknown

Community Program Homeless Shelter

Other Unlicensed Assisted Living

Correctional Institution

Hospital Rehabilitation Facility

Incident Location Name:___________________________________________________

Incident Location Phone Number:___________________________________________

Description of Incident: ___________________________________________________

Results of Abuse:

No Physical Injury Care Provider Required Other

Minor Medical Care Death Unknown

Hospitalization Mental Suffering Financial Loss

Rape Kit Needed: Yes No Unknown

Nature of Incident: One Time Incident Ongoing Unknown

Law Enforcement Involvement:

Previously Notified Notification – Emergency

Notification – Not Necessary Notification – Non-Emergency

Law Enforcement Agency:__________________________________________________

Date Law Enforcement Notified:________________________________________

Risk to PS Worker: Yes No Unknown

If you mark Yes to this question, be sure to complete the Threats to Worker Safety and Hazardous Environmental Conditions work flow wizards in the Harmony for APS system.

Agencies to Notify:

Department of Mental Health Department of Child and Family Services

Department of Developmental Services Attorney General’s office

Department of Public Health District Attorney

Disabled Persons Protection Commission

Allegations Please select an Allegation Type(s) and at least one Allegation Sub-type below.

ABUSE

Alcohol

/substance abuse

Corporal

Punishment

Injured with

Weapon

Physical

Restraint

Choked /Strangled

Physical abuse

Cuts

/wounds/burns

Internal

Injuries

Sexual abuse

/ genital trauma

Threat to harm

Bone fracture Death Isolation

/confinement

Sexual abuse/sexual assault/rape

Verbal abuse

Bruises/Welts Emotional

Abuse

Medication

/medical abuse

Sexual abuse

/ harmful genital practices

Chemical

Restraint

Emotional

Trauma

Other Sexual abuse

/ sexual misuse

/exploitation

Allegation Description:

NEGLECT

Abandonment Failure to

Thrive

Inadequate utilities

Malnutrition /

Dehydration

Unsafe environment

(illegal activities)

Alcohol, Drug

Abuse Caretaker

Forced from home (eviction)

Inadequate / dangerous housing

Medical neglect

(medications/doctor)

Inappropriate /

Inadequate

Care / Services

Disregard for personal safety

Inadequate food/malnutrition

Isolation

(social/physical)

Other Finances not managed properly

Emotional

Neglect

Inadequate or improper supervision

Locked in/out of home / room

Squalid Living

Conditions

EXPLOITATION

Undue

Influence

Financial management need

Other Unexplained

Disappearance of

Funds

Embezzle

Financial exploitation

Intent to

Exploit

Parasitic

Relationship

Misappropriation of Assets

Financial Need

SELF NEGLECT

Alcohol

/substance abuse

Heavy chore responsibility

Mental Health

Concerns

Disregard for

Personal Safety

Forced from home (eviction)

Confused Inadequate utilities

Mentally

Retarded

Medical

Neglect

Consumer

Fraud or Scams

Failure to

Thrive

Inadequate / dangerous housing

Other Finances not

Managed Properly

Filth, vermin, squalor

Malnutrition / dehydration

Suicidal Inappropriate /

Inadequate Care /

Services

Alleged Perpetrator

Asian Unknown

Date of Birth:_________________________

Alleged Perpetrator Legal Status:

Biological Child Other Spouse

Collateral Contact Other Family Staff

Attorney

Dentist Landlord Other Professional

Step Sister

Aunt Doctor Lawyer Parent Step Parent

Bank Domestic Partner

Law Enforcement

Self Teacher

Brother Elected Official

Legal Guardian

Sibling Uncle

Caregiver Friend Neighbors Sister Personal Care Attendant

Church Grandchild Non-Relative Social Worker Wife

Cousin Health/ Medical

Professional

Best Time to Contact:___________________________________________

Hair Color: ________________________ Eye Color: _____________________

Height: ________________________ Weight: _______________________

Alleged Perpetrator Whereabouts: ________________________________

Access to Alleged Victim: Yes No Unknown

Access to Funds: Yes No Unknown

If you mark Yes to this question, be sure to complete the Financial Risk Assessment workflow wizard in the Harmony for APS system.

Other Participants

Title:_____________________________________________________________

Asian Unknown

Other Participant’s Legal Status:

Relationship to Involved Adult:

Attorney

Dentist Landlord Other Professional

Step Sister

Aunt Doctor Lawyer Parent Step Parent

Bank Domestic

Partner

Law

Enforcement

Self Teacher

Brother Elected

Official

Legal

Guardian

Sibling Uncle

Caregiver Friend Neighbors Sister Personal Care

Attendant

Church Grandchild Non-Relative Social Worker Wife

Cousin Health/ Medical

Professional

Biological Child Other Spouse

Collateral Contact Other Family Psychologist

Decision

Screening Priority: Priority Review Normal Review

Screening Queue:___________________________________________________

Decision Comments & Response Time Reasons:______________________

Other Participants

Title:_____________________________________________________________

Asian Unknown

Other Participant’s Legal Status:

Relationship to Involved Adult:

Attorney

Dentist Landlord Other Professional

Step Sister

Aunt Doctor Lawyer Parent Step Parent

Bank Domestic Partner

Law Enforcement

Self Teacher

Brother Elected Legal Sibling Uncle

Official Guardian

Caregiver Friend Neighbors Sister Personal Care Attendant

Church Grandchild Non-Relative Social Worker Wife

Cousin Health/

Medical Professional

Biological Child Other Spouse

Collateral Contact Other Family Psychologist

Alleged Perpetrator

Asian Unknown

Alleged Perpetrator Legal Status:

Biological Child Other Spouse

Collateral Contact Other Family Staff

Attorney

Dentist Landlord Other

Professional

Step Sister

Aunt Doctor Lawyer Parent Step Parent

Bank Domestic Partner

Law Enforcement

Self Teacher

Brother Elected Official

Legal Guardian

Sibling Uncle

Caregiver Friend Neighbors Sister Personal Care Attendant

Church Grandchild Non-Relative Social Worker Wife

Cousin Health/

Medical Professional

Hair Color: ________________________ Eye Color: _____________________

Height: ________________________ Weight: _______________________

Alleged Perpetrator Whereabouts: ________________________________

Access to Alleged Victim: Yes No Unknown

Access to Funds: Yes No Unknown

If you mark Yes to this question, be sure to complete the Financial Risk Assessment workflow wizard in the Harmony for APS system.