Submit Child Abuse Form to Teresa Li

Child Abuse Submission Form
Fields marked with * are required
Your submission will be kept confidential

* Indicates required field

Your Name *

First

Last

Child's Name *

First

Last

Child's Date of Birth *

Phone Number *

Your Email *

Child's Disability, If Any *

Date of Incident(s) *

Incident(s) Reported to the Police or CPS? *

Yes No

If Reported, Date of Reporting *

Date Parent/Guardian First Learned of Incident(s) *

If Reported to the Police or CPS, Who Reported It? *

Describe Incident(s) *

Describe Any Changes Observed in Child's Behavior *

School District *

Perpetrator's Name *

First

Last

Photographs of Injuries Available? *

Yes No

School, Day Care, Camp, Scout or Other Institution's Name *

Perpetrator's Relationship to Your Child *

Disclaimer: By submitting this form, I understand that it does not establish an attorney-client relationship. *

I have read and understand the disclaimer

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