ADDITIONAL INFORMATION ABOUT THE SUBJECT BEING REFERRED (Adult at Risk) Normal care needs of the person being referred, if known: Who provides this: Why can the adult at risk not protect themself? Does the adult at risk have/need an advocate? Yes / No Give details: What action has been taken to safeguard the adult at risk? CAPACITY / CONSENT Is the adult at risk subject to legislative powers, such as DoLS, MHA or Power of Attorney? Yes / No Specify: Is there any evidence to suggest that the adult at risk lacks mental capacity to consent to this referral? Yes / No Next of Kin / Person with legal responsibility / Adult at risk’s chosen representative (delete, as appropriate): If the adult at risk has capacity, do they consent to their information being shared with other agencies? Yes / No Relationship: Is there an overriding reason to share this concern without consent? (e.g. a crime has been committed, others may be at risk) Yes / No If yes, please explain why: Address: Telephone: Is the adult at risk aware of the referral? Yes / No If not, please explain why: Has the adult at risk been informed that their information will be shared without consent, where necessary? Yes / No Signature of Adult at Risk (or person with legal responsibility) consenting to referral: ……………………...………………..………………… Name: Date:
ABOUT THE ALLEGED ABUSE: Type of alleged abuse: (tick all relevant boxes) Physical Sexual Emotional/Psychological Financial/Material Neglect Is this Organisational / Institutional Abuse? If the concerns impact on three or more service users, then only one single referral is necessary. Where did the alleged abuse occur? Own Home Care Home - Residential Care Home – Nursing Care Home – Respite Relative’s Home Supported Tenancy Hospital Hospital – Independent NHS Trust Group Home Home of Perpetrator Day care Educational Sheltered Accommodation Hospice Public Place Other - Please State: Is the abuse: Historical Current Additional risks/concerns? Racial Abuse Domestic Abuse Substance Misuse REASON FOR REFERRAL / NATURE OF CONCERNS: (including how and why those concerns have arisen, if known)
ABOUT THE PERSON(S) ALLEGEDLY RESPONSIBLE FOR THE ABUSE: Unknown at present: More than one alleged perpetrator? Yes / No (Add details to additional information box on next page) Name: Address: Telephone: DOB: Age: Relationship to Alleged Victim: Perpetrator’s Employing Agencies: (List all known) Volunteer? Yes / No Is the alleged perpetrator an adult at risk? Yes / No / Don’t know If the alleged perpetrator is an adult at risk, do they have capacity to understand their actions? Yes / No / Don’t know Is alleged perpetrator a child? Yes / No / Don’t know Is alleged perpetrator aware of the referral? Yes / No / Don’t know Is alleged perpetrator known to Social Services, Health or Police? ABOUT THE PEOPLE WHO WITNESSED THE INCIDENT(S): Name of Witness Address, inc Post Code Telephone no. Relationship to victim (if any) Is witness a child? Is witness an adult at risk? Is witness aware of referral? WHO HAS RAISED THE CONCERN? Name Address, inc Post Code Telephone no. Relationship to victim (if any) Occupation / Employer When was the disclosure made Does the reporter wish to remain anonymous? Yes / No If yes, explain why: (excludes professionals)