Child Abuse/Neglect Referral Form |
For emergencies that require immediate action or children in need of medical attention, please call the Clark County Abuse Hotline (702) 399-0081 |
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Instructions |
Complete each applicable field to the best of your ability
After filling out the form, click the Submit button to send the information to the Child Abuse & Neglect Hotline
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Source Information |
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Mandated Reporter Info |
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Child Abuse/Neglect Victim(s) |
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Child Abuse/Neglect Referral Participants |
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Description of Child Abuse/Neglect |
Please provide a current description |
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1) What is the abuse and/or neglect? |
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2) Describe the child(ren)'s injury. Include marks, bruises, injuries, location, size, color, and child(ren)'s reaction to the injury. |
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3) What are the circumstances surrounding the abuse and/or neglect? Include date of most recent incident, events surrounding incident, events following incident, and frequency of abuse and/or neglect. |
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4) Describe how the child(ren) function(s) on a daily basis (i.e., school they attend, diagnoses, special needs, behavioral problems). |
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5) Describe how the parents (primary caretakers) function on a daily basis. Please include: employment; substance abuse, type of substance, frequency of substance abuse, last time substance was used, behavior when using substance, interaction with child(ren) while under influence of substance; mental health diagnoses or physical disabilities; use of prescription or self-medication for diagnoses or disabilities; domestic violence or criminal history. |
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6) Describe the general parenting practices in this family. Include how the child(ren)'s basic needs are met; if the adults (primary caretakers) are bonded or attached to the child(ren); if there is a court order custody arrangement, please provide primary custodial name and address. |
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7) How do the parents (primary caretakers) discipline? Include why the child(ren) are disciplined; what is used to discipline the child(ren); if discipline is used, where on their body does this occur; the last time any discipline occurred. |
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8) When and how did you become aware of the abuse and/or neglect? |
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11) If there is or has been domestic violence in the home, what does it entail? How does it affect the children? For example, is the domestic violence physical or verbal? Are items thrown, and are the children intervening? |
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12) Are you aware of any past abuse, neglect or domestic violence? If so, please be as descriptive as possible about the "who, what, when, where, how, and why." |
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Conclusion |
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What is the current condition of the child(ren)? |
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Please email any pertinent information about your concerns to DFSIntake@clarkcountynv.gov. Examples include: photographs, videos, text messages, medical documentation, educational records, etc. |
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