Please complete this form as fully as possible.
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Telephone number (please tell us if there is no known number or if there are special instructions relating to the phone number)
* Please state their current location
* What does the adult want to happen as an outcome of the referral?
Who would the adult like to support or represent them?
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
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)
Details of the person who has allegedly caused harm
Details of the person making this referral
* Telephone number (please tell us if there is no known number or if there are special instructions relating to the phone number)