Illinois Department on Aging
ANE INTAKE FORM
SECTION A: CASE CONTROL INFORMATION
CLIENT # DATE OF INTAKE INTAKE TIME AGENCY NAME TYPE
AM PM 800U RAA AGENCY
SECTION B: VICTIM INFORMATION
ALLEGED VICTIM’S NAME AGE PHONE
ESTIMATE
ADDRESS (street, city, county, zip):
DIRECTIONS TO THE HOME:
BEST TIME/PLACE TO REACH ALLEGED VICTIM:
SECTION C: PRIORITY AND DANGER
REASON REPORT WAS CATEGORIZED AS ELDER ABUSE PRIORITY CODE I II III
60 OR OVER ALLEGATIONS CONSTITUTE ANE DOMESTIC SETTING ALLEGED ABUSER EXISTS – EXPLAIN REASONS AND PRIORITY:
CLIENT IN IMMEDIATE DANGER? NO YES UNKNOWN – SPECIFY:
CLIENT IN NEED OF IMMEDIATE ASSISTANCE? NO YES UNKNOWN – SPECIFY:
CLIENT’S PHYSICAL / MENTAL CONDITION:
DANGEROUS SITUATION? NO NEIGHBORHOOD ? ANIMALS? MI/DRUGS? WEAPONS? UNKNOWN – EXPLAIN:
SECTION D: ALLEGED ABUSER INFORMATION TOTAL NUMBER OF ALLEGED ABUSERS
ABUSER #1 NAME ABUSER #2 NAME
ADDRESS ADDRESS
PHONE AGE PHONE AGE
ESTIMATE ESTIMATE
RELATIONSHIP TO ALLEGED VICTIM RELATIONSHIP TO ALLEGED VICTIM
A/A’s PHYSICAL / MENTAL CONDITION: A/A’s PHYSICAL / MENTAL CONDITION:
INTAKE.FRM IL-402-0709 (Rev. 02/00
SECTION E: DESCRIPTION OF THE REPORT
REPORTER’S STATEMENT
ABUSE (S) SUSPECTED:
PHYSICAL SEXUAL EMOTIONAL CONFINEMENT P. NEGLECT DEPRIVATION FIN. EXPLOITATION
IS CLIENT AWARE OF THE REPORT? YES NO IS ABUSER AWARE OF THE REPORT? YES NO
SECTION F: REPORTER INFORMATION
REPORTER’S NAME PHONE WILL PROVIDE FURTHER INFO?
YES NO
ADDRESS
REPORTER TYPE (CHECK MOST APPROPRIATE BOX)
SELF PHYSICIAN SIBLING OTHER AGING NETWORK
SPOUSE LEGAL GUARDIAN/DPoA GRANDCHILD EMPLOYEE
CHILD LAW ENFORCEMENT SON/DAUGHTER-IN-LAW OTHER MANDATED REPORTER
OTHER RELATIVE OTHER IN-HOME CARE WKR. BANK/FINANCIAL EMPLOYEE OTHER NON-MANDATED
NEIGHBOR ALLEGED ABUSER STATE EMPLOYEE REPORTER
SOCIAL WKR/COUNS ANONYMOUS CASE MANAGER/EACW
NURSE ATTORNEY CCP EMPLOYEE
MEDICAL PERSONNEL FRIEND TITLE III EMPLOYEE
(Paid or volunteer)
REPORTING REQUIREMENTS (CHECK THE BOX WHICH BEST CATGEGORIZES THE REPORTER’S RESPONSE):
MANDATED REPORTER VOLUNTARY REPORTER UNSURE
NAME ADDRESS
OTHERS
WITH
INFORMATION RELATIONSHIP TO ALLEGED VICTIM AWARE? PHONE
YES NO
CHECK (X) IF N/A
NAME ADDRESS
RELATIONSHIP TO ALLEGED VICTIM AWARE? PHONE
YES NO
SECTION G: AGENCY REFERRAL
REFERRAL DATE REFERRAL TIME AGENCY NAME PHONE AGENCY CODE
AM PM
WORKER RECEIVING REFERRAL REPORT TAKER REPORT TAKER PHONE:
ext.
SECTION H: REPORT TYPE
TYPE OF REPORT INITIAL RELATED INFORMATION SUBSEQUENT