BSS Central Intake Form

Reporter Information

First Name

Last Name

Relationship to Child(ren)

Are you a mandated reporter? Yes No

Job Title

Agency/Facility/School

Phone Number

Email Address

Date/Time Submitted

Street Address

City

State

Zip Code

Enter the address where the child(ren) lives:

Street Address

City

State

Zip Code

Directions to the home

Describe any hazards in the home. Such as dangerous dogs, guns, weapons, etc.

Parent/Caregiver Information

Please provide information about the parents/caregivers who live in the home with the child(ren)

First Name

Last Name

DoB/Approximate Age

Sex

Phone Number

Employer

Employer Phone Number

Child Information

Please provide information for ALL of the children in the home

First Name

Last Name

DoB/Approximate Age

Sex

Race

Name of School Child Attends

Do you suspect that this child is more at risk or needs more care, support, or protection than others of similar age? Yes No

If so, please describe what makes them vulnerable.
Include any known mental or physical disabilities, chronic health issues, or extreme behavioral issues.

Parents who Live Outside of the Home

If there is not a parent who lives outside of the home, write "Not Applicable" in all of the boxes below.

First Name

Last Name

DoB/Approximate Age

Phone Number

Street Address

City

State

Zip Code

Allegations of Child Abuse and/or Neglect

For each question, please provide as many details as possible regarding the person suspected of abusing or neglecting the child(ren).

If you do not know the answer, please write "Unknown" in the box

What is the name of the person?

What is their relationship to the child(ren)?

What is their phone number?

Do they live in the home with the child(ren)? Yes No

If no, what is their address?

Describe your concerns about the child(ren) and the family.
Please provide as many details as possible about how the child(ren) has been harmed or is unsafe. Include any known information about what specifically happened, when it happened, who was responsible for the child at the time, and how the parents/caregivers behaved before, during, and after the incident(s).

Does the child(ren) have any injuries right now? Yes No

If yes, describe the injuries. Include nature of the injury, size, color, location, what caused the injury, etc.

Where is the child(ren) at right now? Include address and phone number

How long will the child(ren) be there?

Has any parent/caregiver in the household acted in a way to keep the child(ren) safe? Yes No

If yes, describe what actions they took.

Does the family have any prior history with Child Protective Services (CPS)? Yes No

If yes, describe when, how long, and why they were involved.

Where parents/caregivers at right now? Include address and phone number

How long will the parents/caregivers be there?

Do the parents/caregivers use alcohol or drugs? Yes No

If yes, describe how this is harming the child(ren).

Do the parents/caregivers have mental health issues? Yes No

If yes, describe how these issues are harming the child(ren).
Include any suspected or known diagnoses and details about behavior.

Is there any domestic violence between the parents/caregivers? Yes No

If yes, describe what the child(ren) has/have witnessed or experienced.
Include any known info about hwo the primary aggresor is, what specifically they are doing to the other person, how often it occurs, how long it has been going on, if the violence has increased, any patters of controlling behaviors, use of physical/emotional/sexual violence, use of force, etc.

What are the overall, typical parenting practices used by all of the parents/caregivers in the home?
Include any known information about parenting styles, attitudes towards the child(ren), knowledge of basic care, how they talk to the child(ren), age-appropriate expectations, etc.

Describe how the parents/caregivers discipline (i.e., punish) the child(ren) if they do something wrong. Give examples if known.

Describe any positive parent-child interactions or strengths that the parent/caregiver has.

Other People Who Would Be Willing to Speak to a Caseworker

If there is not anyone who would be willing to speak to a caseworker, write "not applicable" in the boxes below

First Name

Last Name

Phone Number

How do they know the family?