REFERRAL FORM

  • Date Completed:

  • A. Victim

    • First Name:*
    • Last Name:*
    • Age:
    • Date of Birth:
    • SSN:*
    • Gender:
      • Male
      • Female
    • Ethnicity:
    • Language:
      • Non-verbal
      • English
      • Other
    • Address (If Facility, Include name & Location):
    • City:
    • Zip Code:
    • Telephone:
    • Present Location (If different from above):
    • City:
    • Zip Code:
    • Telephone:
    • Label:
      • Select one
      • Elderly (65+)
      • Developmentally Disabled
      • Mentally Ill/Disabled
      • Physically Disabled
      • Unknown/Other
    • Label:
      • Select one
      • Lives Alone
      • Lives with Others

  • B. Suspected Abuser

    • Name of Suspected Abuser:
    • Address:
    • City:
    • Zip Code:
    • Telephone:
    • Care Custodian (type):
      • Parent
      • Son/Daughter
      • Other
    • Health Practitioner:
    • Spouse
    • Other
    • Gender:
      • Male
      • Female
    • Ethnicity:
    • Age:
    • Date of Birth:
    • Height:
    • Weight:
    • Eyes:
    • Hair:

  • C. Reporting Party

    • Name:*
    • Signature:
    • Email:*
    • Occupation:
    • Agency/Name of Business:
    • Relation to Victim/How Abuse Is Known:
    • Address:
    • City:
    • Zip Code:
    • Telephone:*

  • D. Incident Information

    • Address where incident occurred
    • Date of Incident(s):
    • Place of Incident:
      • Own Home
      • Community Care Facility
      • Hospital / Acute Care Hospital
      • Home of Another
      • Nursing Facility / Swing Bed
      • Other

  • E. Reported Types of Abuse Check All That Apply

    • Perpetrated By Others:
      • Physical (e.g., assault/battery, constraint or deprivation, chemical restraint, over/under medication)
      • Sexual
      • Financial
      • Neglect (including Deprivation of Goods and Services by a Care Custodian)
      • Abandonment
      • Isolation
      • Abduction
      • Psychological/Mental
      • Other
    • Self-Neglect:
      • Physical Care (e.g., personal hygiene, food, clothing, shelter)
      • Medical Care (e.g., physical and mental health needs)
      • Health and Safety Hazards (e.g., risk of suicide, unsafe environment)
      • Malnutrition/Dehydration
      • Financial Self-Neglect (e.g., inability to manage one's own personal finances)
      • Other
    • Abuse that Resulted In:
      • No Physical Injury
      • Minor Medical Care
      • Hospitalization
      • Care Provider Required Death
      • Mental Suffering
      • Serious Bodily Injury
      • Other

  • F. Reporter's observations, beliefs, and statements by victim if available.
    Does alleged perpetrator still have access to the victim? Does the allegation involve a serious bodily injury? Provide any known time frame (2 days, 1 week, ongoing, etc.). List any potential danger for investigator (animals, weapons, communicable diseases, etc.). Check if medical, financial (account information, etc.), photographs, or other supplemental information is attached.

    • Reporter's Observations:

  • G. Other person believed to have knowledge of abuse

    • Name:
    • Relationship:
    • Address:
    • City:
    • Zip Code:
    • Telephone:

  • H. Family member or other person responsible for victim's care

    • Name:
    • Relationship:
    • Address:
    • City:
    • Zip Code:
    • Telephone:

  • I. Reported to Whom

    • Reported to Whom:
      • Attorney
      • Legal Aid
      • APS
      • Law Enforcement
      • Local Ombudsman
      • CA Dept. of State Hospitals
      • CA Dept. of Developmental Services
      • Other
    • Name of Official Contacted by Phone:
    • Telephone:
    • Date:
    • All necessary information has been entered:*
      • YES

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