Safeguarding Referral of an Adult at Risk

This form is to be used only for reporting suspected abuse or neglect of an adult at risk. It is important to give as much information as possible in the report form. If you do not give a full account of what has happened, the process of protecting the adult at risk may be prolonged.

An adult at risk is n adult who:

Is experiencing or is at risk or abuse or neglect
Has needs for care and support
As a result of those needs, is unable to protect himself or herself against the abuse/neglect or the risk of it.

Date form completed and sent

Date(s) of incident(s) if known

Individual Details

Name of individual

First Last

Sex

Male

Female

Date of birth

Gender identity

Individual's Current Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Any other adults/children at risk living at the property

Yes

Unsure

Telephone Number

Email Address

Preferred Language

Interpreter required

Yes

If interpreter required, please give details

Additional Information

About the individual believed to be at risk of abuse or neglect

Is the person at risk of abuse or neglect?

Yes

Describe the risks

Is there evidence that the person has been abused or neglected?

Yes

Describe what has happened

Is the person currently being abused or neglected?

Yes

Describe what is happening

Does the person have care or support needs?

Yes

Please describe their needs

Is the person able to protect themselves against the risk of abuse or neglect?

Yes

If NO, please say why they are unable to protect themselves

Is the individual aware of the referral?

Yes

If NO, why?

Has the individual consented to the referral?

Yes

If NO, why is the referrer continuing with the referral?

Is there any evidence to suggest that the individual lacks mental capacity to consent/understand the concerns and/or process?

Yes

If YES, has an advocate been informed?

Yes

If No (no advocate informed), Why?

Details of the formal/informal family or friend or advocate (if applicable)

IT IS EXPECTED THAT YOU HAVE DISCUSSED THIS SAFEGUARDING REPORT WITH THE INDIVIDUAL OR THEIR ADVOCATE AND MADE THEM AWARE YOU ARE REPORTING THE CONCERN TO AN ADULT SOCIAL CARE, IF YOU HAVE NOT DONE SO PLEASE EXPLAIN WHY

About the alleged abuse

Type of alleged abuse (tick all relevant boxes)

Financial/Material

Neglect

Physical

Sexual

Emotional/Psychological

Describe the alleged abuse or neglect

How long has the alleged abuse been taking place?

Where did the alleged abuse occur?

When did the alleged abuse occur?

How often and to what degree has the abuse been taking place?

What is your view of the impact the abuse is having on the individual?

What steps have been taken and by whom?

Include how the risk has been managed, what others have been informed – including statutory agencies, GP, Police etc.

What are the individual’s views, wishes and feelings about the safeguarding concern? (including actions taken or desired)

About the person(s) allegedly responsible for the abuse

Status

Unknown at present

Name

First Last

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Telephone Number

Date of birth

Age

Relationship to alleged victim

Do they have capacity to understand their actions

Yes

Don’t know

Does the alleged perpetrator provide care and support for the individual?

Yes

Don’t know

Does the alleged perpetrator have care and support needs?

Yes

Don’t know

Is the alleged perpetrator a professional / do they provide care / or have contact with other vulnerable people?

Yes

Don’t know

About any person(s) who witnessed the incident(s)

Name

First Last

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Telephone Number

Occupation/Relationship to victim (if any)

Referrer anonymity

Does the referrer wish to remain anonymous?

Yes

If YES, please state why

This form was completed by

Name

First Last

Time/Date completed

Company

Designation

Phone

Details of the safeguarding department and professionals receiving the referral

Date

Time

Type of referral

Online

Call

Professional accepting referral