Division of Aging and Adult Services

APS is aware that some individuals are receiving error messages upon their submission of an APS on-line report.
 The error message appears to be a system issue. Please note that the on-line report has been received by APS and that APS is working to resolve the issue.

Arizona Adult Protective Services Abuse / Neglect / Exploitation Reporting Form

Don't wait for APS to respond if this is a true emergency situation.
Call 911 immediately!


If you close this window prior to submitting the form, your information will be lost and you will have to start over.

To submit a report anonymously, please call the Central Intake Unit at (877) 767-2385 during normal business hours. Faxes can be sent to (602) 277-4984. You may download the APS Intake form in English (180 KB Word Doc) or Spanish (203 KB Word Doc).


Directions:

  • Use the <TAB> key to navigate through the form
  • Please don't use the <ENTER> key! It could accidently submit an incomplete report and you'll have to start over!

* = Required Field

 

Reporter (Information that pertains to you)

Name: *First:
*Last:
Gender:
Phone Number 1: *Day Time:
Ext:
Phone Type:
Phone Number 2: Night Time:
Ext:
Phone Type:
Mailing Address: Street Address / P.O. Box, etc.
 
Address Type:
City:
  State:
Zip Code:
 
Place of Employment:
 
*Email Address:
*Your relationship to the Client / Victim:  

Client / Victim (Information that pertains to the Adult you are concerned about)

*Is the Client / Victim a Vulnerable Adult?
              
*Is the Client / Victim Incapacitated?
                                               
*First Name:
*Last Name:
Date of Birth: *Approximate Age:
(Must be 18 or older)
If you are concerned
about someone under
the age of 18, please
call the Child Abuse Hotline at
1-888-767-2445
Demographics: Marital Status:
*Gender:
Ethnicity:
*Is this person currently in a Hospital, Long Term or Assisted Living Facility, etc?
                                               
If YES to the above, please indicate the type of Facility:
Please provide the Name, Address, and Phone Number of the Facility:  
Admit Date:  Anticipated Release Date:

Residence and Contact Information (Information that pertains to the Adult you are concerned about)

*Street Address:
 
Residence Type:
*City:
*Zip Code:
*Is the Client currently at a home address?


*Is the address on a Native Tribal Land?
             
Cross Streets:
 
Present location of client if other than home residence:
 
Client's contact phone number:
*Primary language spoken by Client:
Client's financial monthly income:
Client's Income source(s):
 

Safety and Security Information (Client / Victim)

*Are there weapons or any dangers present in the Client's home? (Guns, Dogs, Drugs, etc.)
                                               
If yes, please describe:

*If no dangers, or these are unknown, please type "None"
 
*Has Law Enforcement (Police/Fire Department/etc.) been contacted?
                                               
If Law Enforcement was contacted, please provide any report numbers (if available)
 

Alleged Perpetrator (Person suspected to have abused, neglected, or exploited the Client indicated above)

Name: First:
Last:
Gender:
Phone Number 1: Day Time:
Ext:
Phone Type:
Phone Number 2: Night Time:
Ext:
Phone Type:
Mailing Address: Street Address (cannot be P.O. Box):
 
Address Type:
City:
  State:
Zip Code:
 
Primary Language Spoken:  
Their relationship to the Client / Victim:

Safety and Security Information (Alleged Perpetrator)

*Are there weapons or any dangers present at this person's home? (Guns, Dogs, Drugs, etc.)
                                               
If yes, please describe:  
*If no dangers, or these are unknown, please type "None"
 

Significant Other
Information for any 'Significant Other' of the Adult you are concerned about. This may include a family member or a non-related close friend.

Name: First:
Last:
Gender:
Phone Number 1 Day Time:
Ext:
Phone Type:
Phone Number 2 Night Time:
Ext:
Phone Type:
Mailing Address: Street Address / P.O. Box, etc.
 
Address Type:
City:
  State:
Zip Code:
 
Relationship to the Victim/Client:


Client Risk Factors

*Select all that apply (at least one selection is required)

                                               

Please answer the following questions in detail. Specific detail will allow us to better serve the Adult you are concerned about. If you are unable to answer the questions in detail an APS hotline specialist may contact you to obtain further information before an APS report is generated.

*What happened for you to suspect abuse, neglect or exploitation?
(What most current event occurred that led you to filing this report? Please include the date of any incident)

 

*Please describe how the Client is vulnerable:
 

Please list the Client's medical and/or mental diagnosis (if any)

List the name of the Client's / Victim's Doctor, and any medications they are taking

 

  • You may be prompted to complete any required fields left blank.
  • You will see a confirmation message indicating that your report has been successfully received.
  • After submitting this report, please allow a few moments while it is being processed.
  • Please do not hit 'BACK' or the 'SUBMIT REPORT' button again during this process.

Thank you for taking the time to help protect Adult Arizonans!

 


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