Adult Protective Services

This online report will be reviewed by the Santa Cruz County Adult Protective Services (APS) Intake unit during regular business hours, and does not generate an emergency services response.

If this situation requires immediate response for someone’s immediate physical safety or welfare, please call 911. If you are reporting a crime in progress, please call 911.

If this situation involves an active mental health crisis, please call Santa Cruz County Behavioral Health Mobile Crisis at 1-800-952-2335

If the subject of this referral resides outside of Santa Cruz County please contact the APS agency in their county of residence: https://www.cdss.ca.gov/Portals/9/APS/aps-county-contact-list.pdf

If the subject of this referral resides in a licensed care facility, please contact the Long-Term Care Ombudsman at 831-429-1913

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

Public Intake

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Please note fields marked * are required.

Suspected Abuser #1

First Name:

*Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone :

Work Phone :

Cell/Other Phone:

Address:

Lives with client

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:

Home Phone:

Work Phone :

Cell/Other Phone:

Address:

Lives with client

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

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Reporting Party

*First Name:

*Last Name:

Gender:

Ethnicity:

Race:

*Collateral Type:

Resource Type:

Relation to Victim:

*Email:

*Work Place:

*Occupation:

Home Phone:

*Work Phone:

Other Phone:

*Address:

Lives with client

City:

State:

Zip Code:

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

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 Report

What happened today that led you to make this report? (Observations, beliefs, statements made by victim) (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)

If the Alleged Victim is under 60, please describe their cognitive and/or physical limitations. (Do they need a caregiver to meet their basic daily needs? Are they wheelchair dependent? What current third party assistance are you aware of for this person?) (500 characters max)

Is there a potential danger to the investigating worker, or other problem with access? (guns, animals, recent violence etc.)

Yes

If yes please specify: (500 characters max)

Other Persons Believed To Have Knowledge Of Abuse Family Member Or Other Person Responsible For Victim's Care. (If unknown, list contact person) Add Person

First Name:

Last Name:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Email:

Work Place:

Occupation:

Home Phone:

Work Phone:

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

Written Report (Enter information about the agencies receiving this report. Not required if only reporting to APS.) Add Agency

Agency

Contact First Name

Contact Last Name

Mailed

Address

Date

Faxed

Fax Number

Date

Agency

Contact First Name

Contact Last Name

Mailed

Address

Date

Faxed

Fax Number

Date

Agency

Contact First Name

Contact Last Name

Mailed

Address

Date

Faxed

Fax Number

Date

* 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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Activities of Daily Living	Current Evacuee (Natural Disaster)	Likely area of Evacuation (Natural Disaster)
Chronic Health Problems	Developmentally Disabled	Mental Illness
Client is non-ambulatory	Hearing difficulties	Social Isolation
Client Lives Alone	HIV-AIDS	Unknown
Client requires power for medical equipment	Homelessness	Vision difficulties
Client uses oxygen machine	Housing Issues