ADDITIONAL INFORMATION ABOUT THE SUBJECT BEING REFERRED (Adult at Risk) Normal care needs of the person being referred, if known: Why can the adult at risk not protect themself? Who provides this: Does the adult at risk have/need an advocate? Yes / No What action has been taken to safeguard the adult at risk? Give details: CAPACITY / CONSENT Is the adult at risk subject to legislative powers, such as DoLS, Is there any evidence to suggest that the adult at risk lacks MHA or Power of Attorney? Yes / No Specify: mental capacity to consent to this referral? Yes / No Next of Kin / Person with legal responsibility / Adult at If the adult at risk has capacity, do they consent to their risk’s Yes / No chosen representative information being shared with other agencies? (delete, as appropriate): Relationship: Is there an overriding reason to share this concern without consent? (e.g. a crime has been committed, others may be at risk) Address: Yes / No If yes, please explain why: Telephone: Yes / No Is the adult at risk aware of the referral? If not, please explain why: Has the adult at risk been informed that their information will be shared without consent, where necessary? Yes / No Signature of Adult at Risk (or person with legal responsibility) consenting to referral: ……………………...………………..………………… Name: Date:
ADDITIONAL INFORMATION ABOUT THE SUBJECT BEING REFERRED (Adult at Risk) Normal care needs of the person being referred, if known: Who provides this: Why can the adult at risk not protect themself? Does the adult at risk have/need an advocate? Yes / No Give details: What action has been taken to safeguard the adult at risk? CAPACITY / CONSENT Is the adult at risk subject to legislative powers, such as DoLS, MHA or Power of Attorney? Yes / No Specify: Is there any evidence to suggest that the adult at risk lacks mental capacity to consent to this referral? Yes / No Next of Kin / Person with legal responsibility / Adult at risk’s chosen representative (delete, as appropriate): If the adult at risk has capacity, do they consent to their information being shared with other agencies? Yes / No Relationship: Is there an overriding reason to share this concern without consent? (e.g. a crime has been committed, others may be at risk) Yes / No If yes, please explain why: Address: Telephone: Is the adult at risk aware of the referral? Yes / No If not, please explain why: Has the adult at risk been informed that their information will be shared without consent, where necessary? Yes / No Signature of Adult at Risk (or person with legal responsibility) consenting to referral: ……………………...………………..………………… Name: Date:
adults-at-risk-multi-agency-referral-form-marf.docx