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).
- 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)
Client / Victim (Information that pertains to the Adult you are concerned about)
Residence and Contact Information (Information that pertains to the Adult you are concerned about)
Safety and Security Information (Client / Victim)
Alleged Perpetrator (Person suspected to have abused, neglected, or exploited the Client indicated above)
Safety and Security Information (Alleged Perpetrator)
Information for any 'Significant Other' of the Adult you are concerned about. This may include a family member or a non-related close friend.
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!