Sunrise Counseling Services

Abuse Reporting Form

Under the Florida Mental Health Act (Florida Statute §394.4593), it is mandatory to report any
incidents or suspicions of abuse involving patients receiving mental health counseling services.
This form is in accordance with the provisions of the Florida Mental Health Act.

Reporter Information:
Name: [Your Full Name]
Position/Role: [Your Position/Role at Sunrise Counseling Services]
Contact Information:
● Phone Number: [Your Phone Number]
● Email Address: [Your Email Address]

Patient Information:
Name of Patient: [Patient's Full Name]
Date of Birth: [Patient's Date of Birth]
Patient ID (if applicable): [Patient's Identification Number]

Nature of Abuse:
Please select the type(s) of abuse suspected or reported:
Physical Abuse
Emotional/Psychological Abuse
Sexual Abuse
Neglect
Financial Exploitation

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Description of Incident:

Please provide a detailed description of the incident or suspicion of abuse,

including:
● Date and Time of Incident:
● Location of Incident:
● Description of the Incident:
● Any Injuries Observed:
● Any Witnesses Present:

Description:

Immediate Action Taken (if any):

Describe any immediate actions taken in response to the incident or suspicion of abuse:

Witness Information (if applicable):

Name(s) of Witness(es):

 Witness 1: [Name]
Contact Information: [Phone Number or Email Address]
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 Witness 2: [Name]
Contact Information: [Phone Number or Email Address]

Please provide any additional comments, information, or concerns related to this report:

Confidentiality:
All information provided in this form will be treated confidentially and shared only with
appropriate personnel involved in investigating and addressing the reported incident. Your
cooperation and prompt reporting are greatly appreciated.

Submission Instructions:
Please submit this form to the appropriate supervisor or designated personnel responsible for
handling abuse reports.

Patient

Signed: _____________________________________

Name: _____________________________________

Date: _____________________________________

Sunrise Counseling Services

Signed: _____________________________________

Name: _____________________________________

Date: _____________________________________

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