Please provide details of any other agencies involved that will be able to help with the safeguarding adults enquiry: Are you that there have there been any previous referrals made Yes No in relation to this adult at risk or alleged perpetrator? If yes, please provide details (e.g. dates, type of abuse, action taken): Are there any risks to others (other adults, children)? Yes No Unknown Please provide details (also include who this information has been shared with e.g. Police, – Children’s Social Care, MAPPA). If there are risks to children you must notify Children’s Social Care. Involvement of the adult(s) at risk The following section is crucial to determining the next steps in the safeguarding adults enquiry and every attempt should be made to complete it as fully as possible. Has the adult(s) at risk given consent for this referral? Yes No If no, please confirm why you have not sought consent or are overriding consent (please tick): Public interest (risks to others) Risk of serious harm Suspected serious crime Seeking consent Adult at risk lacks mental Ability to consent is affected by increase risks to the adult or capacity to provide consent threatening or coercive behaviour others (best interest decision made) Other, please provide details below: Do you think the adult at risk has mental capacity in relation to making Yes No decisions about their safety? If no, has a mental capacity assessment been undertaken? Yes No Do you think that the adult at risk will need support to participate in the Yes No safeguarding adults process? If yes, please provide details of what support may be required: If support is needed, is a suitable person who could Yes No Unknown represent them? (e.g. family member, friend, advocate) Please provide the name and contact details of this suitable person: Has the adult at risk’s family been informed of the concerns (where the Yes No adult has consented to this)? What does the adult at risk (or their representative) say that they want to happen as a result of the safeguarding adults enquiry (their desired outcomes)? Signed: Date: Printed: Time:
Please provide details of any other agencies involved that will be able to help with the safeguarding adults enquiry: Are you that there have there been any previous referrals made in relation to this adult at risk or alleged perpetrator? If yes, please provide details (e.g. dates, type of abuse, action taken): Yes No Are there any risks to others (other adults, children)? Yes No Unknown Please provide details (also include who this information has been shared with – e.g. Police, Children’s Social Care, MAPPA). If there are risks to children you must notify Children’s Social Care. Involvement of the adult(s) at risk The following section is crucial to determining the next steps in the safeguarding adults enquiry and every attempt should be made to complete it as fully as possible. Has the adult(s) at risk given consent for this referral? Yes No If no, please confirm why you have not sought consent or are overriding consent (please tick): Public interest (risks to others) Risk of serious harm Suspected serious crime Adult at risk lacks mental capacity to provide consent (best interest decision made) Other, please provide details below: Ability to consent is affected by threatening or coercive behaviour Seeking consent increase risks to the adult or others Do you think the adult at risk has mental capacity in relation to making decisions about their safety? Yes No If no, has a mental capacity assessment been undertaken? Yes No Do you think that the adult at risk will need support to participate in the safeguarding adults process? If yes, please provide details of what support may be required: Yes No If support is needed, is a suitable person who could represent them? (e.g. family member, friend, advocate) Yes No Unknown Please provide the name and contact details of this suitable person: Has the adult at risk’s family been informed of the concerns (where the adult has consented to this)? Yes No What does the adult at risk (or their representative) say that they want to happen as a result of the safeguarding adults enquiry (their desired outcomes)? Signed: Date: Printed: Time:
NTWC24-App5c-2-NorthTyneSGEnqFm-V04.2-Iss-1-Feb-18.docx