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ABOUT US
- INFO
- BOARD & STAFF
ELDER SHELTER
BEHAVIORAL HEALTH
FIDUCIARY EDUCATION
- UPCOMIG TRAININGS
FORENSIC TEAM
- ASSESSMENT SERVICES REFERRAL
NEWS & RESOURCES
CONTACT
MORE

Use tab to navigate through the menu items.

PPEJC Elder Shelter Intake Form

Referring Party/Agency

Name & title of person making referral

Phone

Extension

Fax

Email

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

Long-term Medicaid

Yes

No

Unsure

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.

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Let's Connect

Phone: 719-318-7459

Address: 10 E Monument St Colorado Springs, CO

The PPEJC is not a crisis, intake or housing center. We partner with community resources to address the mistreatment of older adults.

ABOUT US
- INFO
- BOARD & STAFF
ELDER SHELTER
BEHAVIORAL HEALTH
FIDUCIARY EDUCATION
- UPCOMIG TRAININGS
FORENSIC TEAM
- ASSESSMENT SERVICES REFERRAL
NEWS & 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.

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