Family Services | Child Abuse/Neglect Referral Form
Child Abuse/Neglect Referral Form
For emergencies that need immediate attention, please call the Clark County Abuse Hotline (702) 399-0081
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

  • Source Information
    Please provide your name and phone number. The hotline may call you back if additional information is needed
    Would you like our hotline to contact you confirming receipt of this email?
     
     
    Best time to call?
    Day Evening Any time  
    Last Name
    Phone Number  
    Email  
    Child Abuse/Neglect Victim(s)
    Child 1 - Victim
      Gender Male Female    
    Language
    Last Name
    Child attends school? Yes No Unknown
     
    School Name
    Age  

    Child 2 - Victim
      Gender Male Female    
    Last Name
    Child attends school? Yes No Unknown
     
    School Name
    Age  

    Child 3 - Victim
      Gender Male Female    
    Language
    Last Name
    Child attends school? Yes No Unknown
     
    School Name
    Age  

    Child 4 - Victim
      Gender Male Female    
    Language
    Last Name
    Child attends school? Yes No Unknown
     
    School Name
    Age  

    Child 5 - Victim
      Gender Male Female    
    Last Name
    Child attends school? Yes No Unknown
     
    School Name
    Age  
     
    Child Abuse/Neglect Referral Participants
    Mother's name of child(ren) - victim.
     
      Mother's address and who else resides in the home?
     
    Last Name
    Age

    Father's name of child(ren) - victim.
     
      Father's address and who else resides in the home?
     
    Last Name
    Age

    Please provide the family address and phone numbers.
         Home Phone Number
    Cell Phone Number
    Work Phone Number
    Zip Code  

    Where do the child(ren) reside?
    Is this a foster family? Yes No Unknown  
     
    Description of Child Abuse/Neglect
    Please provide a current description
      1) What is the abuse and/or neglect?  
       
       
       
      2) Describe the child(ren)'s injury. Include marks, bruises, injuries, location, size, color, and child(ren)'s reaction to the injury.  
       
       
       
      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.  
       
       
       
      4) Describe how the child(ren) function(s) on a daily basis (i.e., school they attend, diagnoses, special needs, behavioral problems).  
       
       
       
      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.  
       
       
       
      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.  
       
       
       

     
      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.  
       
       
      8) When and how did you become aware of the abuse and/or neglect?  
       
      9) Where are the child(ren) currently located?   10) Has law enforcement been contacted? Yes No
       
    If yes, please provide date and event number:
    Date
    Event Number
    11) If there is domestic violence in the home, how does this affect the child(ren)?  
     
    Previous abuses, neglect or domestic violence:  
    Do you know about or suspect previous  
      Child abuse or neglect? Yes No Unknown  
      Domestic violenece between parents? Yes No Unknown