Derby Safeguarding Adults Board Referral Form

Please complete this form as fully as possible.

You can save or print a copy of your form by pressing ‘Ctrl + P’ once you have completed all of the fields and before you click ‘Send’.

Your referral will be emailed to Adult Social Care but a copy will not be sent to you by email for security reasons.


The fields marked with an asterisk (*) are required fields. All the information you enter will be submitted securely.

Details of the Adult

* Name of relevant adult
* Date of birth (dd/mm/yyyy) or approximate age of adult
* Ethnic Origin
* Address
Telephone number (please tell us if there is no known number or if there are special instructions relating to the phone number)
* Is the present location of person different from above
* Please state their current location
* Is the adult aware of the referral?
If no, why not?
* What does the adult want to happen as an outcome of the referral?
* Have they consented to the referral?
* Have they got Capacity under the MCA to consent?

If yes, Date of Capacity assessment (dd/mm/yyyy)
Is the adult able to independently represent their views and wishes?
Who would the adult like to support or represent them?
Does the adult need referral to formal advocacy support or services?

Statutory Safeguarding Criteria

* What care and support needs does the adult have? (For example: does the adult have any medical conditions or disabilities such as learning disability, dementia, physical disability, mental ill health etc. Please describe how these conditions impact the adult’s day-to-day life.

Please also explain whether the adult has experienced any trauma, do they have any leaving care status, previous experience of abuse, experiencing coercion or control, etc.

Please also state if the adult is a carer )
* How do these needs prevent the adult keeping themself safe?

Category of alleged abuse/risk of abuse

* Category of alleged abuse/ risk of abuse (select all that apply)









Is the abuse/neglect motivated by any of the following factors? (select all that apply)












Details of alleged abuse/ risk of abuse

* Details of alleged abuse/ risk of abuse/ concerns. Please give as much detail as possible about what the concerns are, what has happened and what risk of future abuse/harm has been identified (Who is involved, What has happened, Where has it happened, When did it happen, How has it happened)
* What immediate safeguarding action has been taken?
* Where has the alleged abuse occurred or is likely to occur (if this is a regulated setting, please provide full address and postcode)
Date of suspected abuse (if known)
Time of suspected abuse (if known)
* Have the police already been informed?

If yes, what is the incident number?
Date of Death (if applicable)
* Does making this referral place anyone at risk of harm including other adults or children? (Think Family- please make a referral to children’s services if you have concerns for the welfare or safety of a child)
If yes, please detail
* Has the abuse or neglect been directly observed?

If yes by whom?

Details of the person who has allegedly caused harm

* Name of person alleged to have caused harm
Date of Birth (if known)
Address (if known)
Is this person a:




Details of relationship
* Is the person who has allegedly caused harm/abuse aware of the referral?

Details of the person making this referral

* Name of referrer and referring agency
* Address
* Telephone number (please tell us if there is no known number or if there are special instructions relating to the phone number)
* Email
* Confirm Email
* Signature of referrer (by typing your name you are signing this electronic form)
* Date alert raised in referring agency

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