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Your First Name (required)
Your Last Name (required)
Your Address
Your City
Your State
Your Zip Code
Your Email (required)
Your Phone Number
What is your relationship with the children?
Have you had a psychological evaluation?
How did you hear about Attorneys for Children?
***The alleged perpetrator is the person and/or organization named as the suspected abuser by your supporting documentation.***
First Name
Last Name
Name of Organization
Address
City
State
Zip Code
Perpetrator's relationship to children (Staff, Teacher etc)?
Did you or someone else contact your local law enforcement agency?
YesNo
If YES, please answer the following:
Law Enforcement Agency
Report Number
Name and contact number of officer
Did law enforcement file charges against the alleged perpetrator?
Is there a pending criminal case?
Court Number
Case Number
Court County
Court State
Did you or someone else contact CPS?
Child First Name
Child Last Name
Child's date of Birth
Child's sex
Allegation of what type(s) of abuse:
Has the child been examined by any other doctor?
Has the child had a psychological evaluation?
Doctor's Name
Psych Exam Date
Is the child attending ongoing therapy?
Has the child made disclosures of abuse to his/her therapist?
Therapist Name
Therapist Exam Date
