REPORT INFORMATION Self Relative/ Independent Local Health Police Reported Friend Hospital Board Source of Provider Ambulance Care Probation Advocate Report Agency Service Regulator Third Local Other Sector Authority Category of Abuse Emotional/ Financial/ or Neglect Physical Sexual Neglect Psychological Material (Tick all that apply) Was this racially motivated? Yes No Was this Domestic Abuse? Yes No Description of alleged abuse/ injuries: (Continue on separate sheet of paper if necessary) Where did the alleged abuse Care Home Health Own Home Community occur? Setting Setting If a care home setting, please state name of home Is the abuse Historical Current Person alleged responsible for Volunteer/ Other Paid Relative/ abuse or neglect (if Self,select Unpaid Service Other Employee Friend Other and add ‘Self’ to box below) employee User If other, please specify: Is the Adult at Risk aware of the referral? Yes No Has the Adult at Risk consented to the referral? Yes No Is there any evidence to suggest that the Adult at Risk lacks mental capcity to consent to this Yes No Not Established referral? Personal circumstances – Is the alleged victim subject to any legislative powers, e.g. Mental Health Act, Power of Attorney, DoLS?
REPORT INFORMATION Source of Report Self Reported Relative/ Friend Independent Hospital Police Local Health Board Provider Agency Ambulance Service Care Regulator Probation Advocate Third Sector Local Authority Other Category of Abuse or Neglect (Tick all that apply) Physical Sexual Emotional/ Psychological Financial/ Material Neglect Was this racially motivated? Was this Domestic Abuse? Yes No Yes No Description of alleged abuse/ injuries: (Continue on separate sheet of paper if necessary) Where did the alleged abuse occur? Own Home Community Care Home Setting Health Setting If a care home setting, please state name of home Is the abuse Historical Current Person alleged responsible for abuse or neglect (if Self,select Other and add ‘Self’ to box below) Paid Employee Volunteer/ Unpaid employee Relative/ Friend Other Service User Other If other, please specify: Is the Adult at Risk aware of the referral? Yes No Has the Adult at Risk consented to the referral? Yes No Is there any evidence to suggest that the Adult at Risk lacks mental capcity to consent to this referral? Yes No Not Established Personal circumstances – Is the alleged victim subject to any legislative powers, e.g. Mental Health Act, Power of Attorney, DoLS?
adult-safeguarding-report-enquiry-form.docx