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Child Maltreatment Report

Disclaimer
Note: certain words are blocked on this website. If you have trouble filling out this form, please call 218-631-7605 and ask for an Intake worker so they can email you a mandated reporter form.
Report of Suspected Child Maltreatment
Reporter:
Name:
Phone:
Email:
Address1
Address2
City
State
Zip
Relationship to child victim:
Are you a mandated reporter? if yes, which agency?
Date you became aware of incident:
Child Victim:
Name:
Date of birth:
School and Grade:
Address:
Who does the child live with?
Continue

Describe the suspected abuse or neglect in detail. Please include as many facts as possible such as, who, what, when, where, and how. Has similar incidences occurred in the past? Has the child expressed fear of parent or situation? If so, what does the child fear?
If there is an injury to the child, describe the nature and extent of the injury such as; size, color, and location. If a picture was taken, please email or send it to Wadena County Human Services
What are possible stressors that could have influenced or affected the incident such as; domestic violence, work problems, substance abuse, poverty, cognitive, or mental health problems?
What are the strengths and resources available to this child and family such as supportive extended family, transportation, and attitude?
What would you like to see happen?
What are your worries if there is no intervention?
Do you know of anyone else who may have knowledge about the incident?
Are parents aware that a child maltreatment report has been made?
Is there reason to believe the child has Native American heritage?

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