Adult Protective Services

If you suspect harm is occurring right now, call 911. This form is for submitting non-emergency reports.

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

Public Intake

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Please note fields marked * are required.

Your Information (Reporter information is kept confidential per Montana Code Annotated)

Anonymous

*First Name:

*Last Name:

Gender:

Ethnicity:

Race:

Collateral Type:

Resource Type:

Relation to Victim:

Email:

Work Place:

Occupation:

Primary Phone:

Home Phone:

Work Phone:

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

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

Client Information

*First Name:

Middle Name:

*Last Name:

* DOB:

OR Age:

Exact Age Unknown

Gender:

SSN: ###-##-####

Language:

Speaks English

Ethnicity:

Race:

Sexual Orientation:

Living Arrangements:

Primary Phone

Home Phone :

Work Phone :

Cell/Other Phone:

* Address:

City:

Zip Code:

Current Location: (if different from address)

Physical/Mental Impairments:

Suspected Abuser #1

First Name:

Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Primary Phone:

Home Phone :

Work Phone :

Cell/Other Phone:

Address:

Lives with client

SSN:

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:

Primary Phone:

Home Phone:

Work Phone :

Cell/Other Phone:

Address:

Lives with client

SSN:

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

SSN:

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Other Persons Believed To Have Knowledge Of Abuse

First Name:

Last Name:

Gender:

DOB:

Race:

Primary Phone:

Home Phone:

Work Phone:

Cell/Other Phone:

Address:

Lives with client

SSN:

City:

State:

Zip Code:

What is this person's relationship to the victim and how are they related to the report?:

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 Reported

* Please fully explain your complaint including any identified physical/mental injuries, monetary loss, etc. (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)

What resources, supports or services does the victim currently receive? (500 characters max)

*Is there a potential danger to the investigating worker, or other problem with access? (Weapons, animals, COVID-19/communicable disease, environmental hazards, etc.)

Yes

If yes please specify: (500 characters max)

* 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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