APS INVESTIGATION CASE CONSULTATION FORM

Case Name:	TWIST Number:	Intake ID:
Worker:	FSOS:	Consult Date:
Date Received:	TYPE OF CASE:	Choose an item.
Victim’s Location:	Safety Concerns:	Fatality:
Evidence Collected: Records Certified: Yes No	What has been done to alleviate concerns?
Audio/Video	Medical Records	UR	EPSO
Court Records	Mental Health Records	Ex Parte	Prevention Plan
Financial Records	Photographs	Court Action	202A
Law Enforcement	Other:	Other:

Agency:	Agency Type:	Choose an item.
Perp:	Compensated Caregiver:	Mailing Address:	SSN:
Perp:	Compensated Caregiver:	Mailing Address:	SSN:
Authorized Agency Involvement:	OAG	OIG	BHDID	Law Enf	LTCO	County Atty	Comm Atty
Agency Report Received:	OAG	OIG	BHDID	Law Enf	LTCO

Allegations (include 2nd incidents):

Collaterals Interviewed

Central Office Consult:	Nurse Consult:
Recommendations:
AOC/Pending Court:
Investigation Details:

Follow Up Tasks to be completed: