Relationship to adult Address: at risk: If the alleged abuser is a staff/volunteer, provide details (include. employer, job role, work address): Please tick or cross YES NO Are they an adult with care and support needs? Details of care and support needs (if applicable): Any details about the alleged abuser(s): Description of the alleged incident/harm Please give a detailed description of the incident (including times), all people involved, witnesses and any other comments you feel are relevant. If the concern relates to physical abuse please provide a body map. Type of abuse Please tick or cross all that apply Physical Sexual Psychological/emotional Financial/material Neglect/omission Discriminatory Self-neglect Domestic abuse/violence Modern slavery Radicalisation/extremism Other If other, please specify: Please tick or cross UKNOWN YES NO Is the adult at risk of further abuse/neglect? What has been done to ensure the immediate safety of the adult at risk and others? (Completing and submitting this form does not constitute management of immediate risks). tick or cross YES NO Please Were the Police called? Please provide the outcome of the Police action and Police log number (if available):
Address: Relationship to adult at risk: If the alleged abuser is a staff/volunteer, provide details (include. employer, job role, work address): Please tick or cross YES NO Are they an adult with care and support needs? Details of care and support needs (if applicable): Any details about the alleged abuser(s): Description of the alleged incident/harm Please give a detailed description of the incident (including times), all people involved, witnesses and any other comments you feel are relevant. If the concern relates to physical abuse please provide a body map. Type of abuse Please tick or cross all that apply Physical Sexual Psychological/emotional Financial/material Neglect/omission Discriminatory Self-neglect Domestic abuse/violence Modern slavery Radicalisation/extremism Other If other, please specify: Please tick or cross UKNOWN YES NO Is the adult at risk of further abuse/neglect? What has been done to ensure the immediate safety of the adult at risk and others? (Completing and submitting this form does not constitute management of immediate risks). Please tick or cross YES NO Were the Police called? Please provide the outcome of the Police action and Police log number (if available):
Referral-Form-Safeguarding-Concern-Final-May-2016.docx