Elder Shelter | Pikes Peak Elder Justice Center

PPEJC

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PPEJC Elder Shelter Intake Form

Referring Party/Agency

Name & title of person making referral

Phone

Extension

Fax

Has the abuse been reported to Police/APS? Who?

Hs the Victim been admitted in the past?

If YES, which facility?

Agency making referral:

Adult Protective Services

Police

Hospital

Other

Agency Address/City/State/Zip

Demographic Information of Victim

First Name

Gender

Middle Initial

Last Name

Date of Birth

Social Security Number

Type of Abuse:

Physical

Sexual

Psychological

Neglect

Financial

Other

Home Phone

Current Address/City/State/Zip

Is it Safe to Contact?

Cell Phone

Is it Safe to Contact ?

Married?

Dating Partner?

Spiritual Preference

Emergency Contact Name

Phone

Relationship to Victim

Is it Safe to Contact?

Insurance Information

Medicare Number

Select One

Medicaid Number

Country

N/A

Medicaid Case Worker Name

Other Insurance

Phone #

ID#

Insurance Information

List of Medical Conditions/Diagnosis:

List of Medications

Allergies

List and dates of recent hospitalizations

List of Psychological Conditions/Diagnosis

Psychological/Medical Health Hospitalizations list and dates

History of Substance Abuse or Alcohol Abuse

Current Usage (indicate what)

Current Smoker? Check all that apply

Tabacco

Marijuana

Vaccination

Social History, include any potential for violence and suicidal ideations

Legal Information

Legan Guardian (if applicable)

Phone

Power of Attorney (if applicable)

Phone

Information Regarding Abusive Situation

Name and Relationship of Person(s) Committing Abuse

Address of person(s) Committing Abuse

Does Person committing Abuse have access to guns or weapons?

Is there a Court order in place?

If YES, what kind

Facility to Review & Contact

Facility to Review & Contact Person

*Please provide any copies of Power of Attorneys, medical cards, Identification cards, Court Orders, (other?)

Facility Address/Fax/Phone

Notes

We have received your form.

Let's Connect

PIKES PEAK ELDER JUSTICE CENTER (New ext)_edited.png

info@ppejc.org

Phone: 719-318-7459

Address: 10 E Monument St Colorado Springs, CO

80903

DONATE

ABOUT US
- INFO
- BOARD & STAFF
ELDER SHELTER
BEHAVIORAL HEALTH
FIDUCIARY EDUCATION
FORENSIC TEAM
PUBLICATIONS & RESOURCES
CONTACT

Note:

PPEJC is not a reporting site for the Mandatory Reporting law CRS 18-6.5-108.

Please contact the law enforcement agency and

Adult Protective Services where the client resides.