CASE INTAKE FORM

Date of Report(Required)

MM slash DD slash YYYY

Name of the reporting party completing this form(Required)

First Last

How did you receive this information?(Required)

Phone number of the individual completing this form(Required)

Email of the individual completing this form(Required)

Best way to make contact if any other information is needed(Required)

Call

Text

Primary Language(Required)

English

Spanish

Other

What language ?(Required)

Relation of the individual to the minor (i.e father, mother, sibling, friend, etc.)

Exploitation / Human Trafficking Suspected(Required)

Yes

Reason for reporting(Required)

MINOR INFORMATION

Minor's First and Last Name(Required)

First Last

Nickname(s)

Date of Birth(Required)

MM slash DD slash YYYY

Age

Drivers license number/ ID number

Minor's identification number

Minor's Address (Last Known Address)

Street Address Address Line 2 City State ZIP Code

Minor's Phone Number

Email Address

Gender(Required)

Female

Male

Transgender Male

Transgender Female

Weight (lbs)(Required)

Height(Required)

Race(Required)

American Indian

Asian

Black

Hispanic

White

Biracial

Other

Pleace define ( Race )(Required)

Complexion(Required)

Light

Medium

Dark

Hair Length(Required)

Shaved

Short

Medium

Shoulder Length

Long

Hair Color(Required)

Black

Blonde

Brown

Gray

Red

Other

Please define ( Hair Color )(Required)

Eye Color(Required)

Black

Blue

Brown

Green

Gray

Hazel

Pink (albino)

Contacts or Glasses?(Required)

Neither

Glasses

Contacts

Any Birthmarks, Scars, Tattoos, or Piercings?(Required)

Minor's identifying marks or characteristics

Clothing worn when last seen(Required)

What was the minor wearing when last seen, including clothes, shoes ,coats, jackets, hats, etc.? Please specify color/style

Any critical needs, or risk factors? (i.e physical, behavioral, or mental health challenges, medications, etc)

Any known/suspected Drug or Alcohol use?

Attend School?(Required)

Yes

If yes, Please list the school name and city

Date of last school attendance

MM slash DD slash YYYY

Last Grade completed

Parents Marital Status

Married

Divorced

Separated

Widowed

Father's Information

Name

Address

Street Address City State ZIP Code

Phone Number

Employer/ Position/ Work Phone Number

Mother's Information

Name

Address

Street Address City State ZIP Code

Phone Number

Employer/ Position/ Work Phone Number

System Involvement

System Involvement(Required)

Foster Care

Agency Name(Required)

Contact Name - CPS / Probation(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Minors current placement

Placement Status(Required)

Name of Placement, person or location(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Any Social Media platform? Facebook, Twitter, Snapchat, TikTok, Live, MSN, and any other social media accounts. Please list the username(s) and login information for each account.

If you are the parent/legal guardian of the missing minor, Do you give Special Operations permission to access the minor's social media account(s)?

Yes

Date / Time minor last seen(Required)

MM slash DD slash YYYY

Time(Required)

Hours

Minutes

AM/PM

When was the last date and time minor was last seen

Location of where the minor was last seen*(Required)

Describe the location where the minor was last seen. Include street address, cross streets, state, etc.

Last seen in the company of

Describe who the minor was last seen with. Friend, Boyfriend, Girlfriend, Father, Mother, etc

Is any photo available?

Drop files here or

Max. file size: 50 MB, Max. files: 5.

Any photo of the minor that you may have.

INVESTIGATING POLICE AGENCY INFO

Have the police been notified?*

Yes

Did they take a missing person's report?

Yes

N/A

If yes, Name of the police agency (Dept)

Detective Name

Detective Phone Number

Address

City State ZIP Code

Police case number

Date police notified

MM slash DD slash YYYY

Do you have a copy of the police report?

Yes

If yes, Please upload the copy of the police report

Max. file size: 10 MB.

Any Historical information, Suspects, and Predators?

Has NCMEC (Missingkids.org) been notified?

Yes

Not sure

Any other information you would like to provide