Report a concern

Name of person reporting concerns*

First Last

Email*

Phone number*

Would you like to remain anonymous?*

Yes
No

Disclaimer: We will make every effort to protect your identity. At times, parties of concern may be able to determine who made the report by the information provided. Please note that we may be legally required by a judge to disclose your information.

Primary caregiver

Name

First Last

Relationship to child

Mother
Father
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Partenal Grandfather

Gender

Age or Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Languages Spoken

English
French

First Nation, Métis or Inuit

If yes, please specify bellow.

FNMI, specify:

Other Caregiver

Name

First Last

Relationship to child

Mother
Father
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Partenal Grandfather

Gender

Age or Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Languages Spoken

English
French

First Nation, Métis or Inuit

If yes, please specify bellow.

FNMI, specify:

Children

Child #1 - Name

First Last

Gender

Age or Date of Birth

Child resides with

Child's school

Languages Spoken

English
French

First Nation, Métis or Inuit

If yes, please specify bellow.

FNMI, specify:

Child #2 - Name

First Last

Gender

Age or Date of Birth

Child resides with

Child's school

Languages Spoken

English
French

First Nation, Métis or Inuit

If yes, please specify bellow.

FNMI, specify:

Child #3 - Name

First Last

Gender

Age or Date of Birth

Child resides with

Child's school

Languages Spoken

English
French

First Nation, Métis or Inuit

If yes, please specify bellow.

FNMI, specify:

Child #4 - Name

First Last

Gender

Age or Date of Birth

Child resides with

Child's school

Languages Spoken

English
French

First Nation, Métis or Inuit

If yes, please specify bellow.

FNMI, specify:

Concern / Narrative (Please provide as much details and information as possible)*

Should you not have enough space for all caregivers/children please include in the narrative/concern

Please describe any observable impact to the child/ren:*

Please tell us how you know this information:*

What is your relationship with the family:*

What supports does the family have? (ex: Grandparent, friends, community agencies, etc.)

History or current concern with any of the following

Please provide an explanation bellow.

Explanation for concerns above:

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All applications are received via email and will be reviewed, from Monday to Friday, between 8:30am and 4:30pm. For urgent protection concerns call immediately : 1-800-461-4236 in Simcoe County and Muskoka.

Primary caregiver

Other Caregiver

Children