STRICTLY CONFIDENTIAL
Safeguarding Children and Adults at Risk of Abuse or Neglect Reporting Concern
Form
Your Details
Is the referral one of the following ? (please tick)
Safeguarding
Prevent
CSE
Modern Day Slavery
Have you gained consent to refer to other agencies, which includes the
Police, SBC Housing Options, Adult Social Care, First Response, Fire &
Rescue Service, Social Housing, New Era, Access Team (Mental Health
Service which will need GP details). Please tick
Yes
No
Time
About the Child/Adult at Risk
child/vulnerable adult:
Nature of concern (please include as much detail as possible):
Extra Questions with regards to referring a vulnerable adult
Have they capacity to
understand?
Yes please tick
If No,
please
tick
Dementia
Alzheimers
Other
Do they own their own
property? Please tick
Home
Owners
Social Housing (if
so, which Housing
Association)
Private Rent
Homeless
Does anyone else live at the
property? Please tick
No
Yes
If yes, name/relationship to
vulnerable adult?
Do they go by any other
names? Please tick
No
Yes
If yes, write name/s here:
Details of action taken:
eg First Response or Vulnerable Adult
Referral made
Name of who you spoke to:
To be completed by the Designated, or Deputy Safeguarding Officer
Eg reported to Police, Hub, First Response,
Adult Safeguarding etc
Child/Adult to make the referral?
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome