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AP1 - final Oct 08 - Version

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					Please Indicate the ongoing level of risk the referred adult is experiencing from this incident:

Low

Medium

High

HEREFORDSHIRE ADULT SAFEGUARDING
REFERRAL
We encourage anyone with concerns to make a Safeguarding referral. You can do this by completing this form or talking to a Customer Services Officer (CSO) or Social Worker, who will complete the form with you. Our contact details are on p5 Please tell us as much as you can.

Team Admin completion
Does the referrer wish to remain anonymous? (See pg 3) Yes No Clix No: Is the referred adult known to social care prior to this referral? Yes No Person responsible to co-ordinate the investigation? Name & Contact Number:

Safeguarding Admin completion
Received by:……………… Date:……………………… Reference No: …………………………….. Has an Adult Safeguarding referral been made about this adult before? Yes No Total referrals for the Person Being Safeguarded …… Is this a :Notification of Concern/Alert Adult Safeguarding Referral Service Provider Referral

Yes No Yes No Yes No

Details of Referred Adult
Please tell us about the Person you feel needs Safeguarding Title: Forename: Home Address: Surname:

Post Code: Tel: Male Ethnic Origin:

Female

DoB: Is this person a carer?

Age: Yes No

Please give details: Do people have difficulty communicating with this person? Yes Please say what would help: Are they placed/paid for in Herefordshire by another Local Authority? Yes First Language: If Yes, please give name of the Local Authority: Name of GP or GP Surgery:

No No

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Why they need help with Safeguarding
Do the following services support them, or do you feel they may be appropriate ? Learning Disability Older Older Person/ Mental Mental Health under 65 Person Health Sensory Disability Physical Disability (inc chronic illness) Substance Misuse HIV/Aids LGBT Other (please specify) Not stated

Details of Incident or Concerns
Please give brief details of what has led to your concerns, including: where the incident took place, who was involved, time and date of incident and any other relevant information.

Are they safe now
Please give details of the steps already been taken to make this person safe. Include any contact with emergency services, doctors, nurses etc

Alleged Abuse
What is the nature of the harm or risk of harm?
Physical Psychological/Emotional Sexual Neglect Self Neglect Discriminatory Other ………………………….. Financial/Material Institutional Not stated

Location of Abuse
Where did this happen?
Care Home

Day opportunities/ College, other education Health Clinic/Surgery/Hospital Other (please specify):

Own Home Workplace Public Place

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Details of Alleged Abuser
Please complete details of alleged abuser
Title: Forename: Surname: Home Address: Post Code: Male Female Tel: If alleged abuser already known to social care, please provide CLIX/Frameworki Number:

DoB:

Relationship of alleged abuser to Person Being Safeguarded (tick as appropriate):
Main family carer Please specify relationship: Staff member Relative Please specify relationship: Service User

Other (eg: Friend, Professional, Volunteer, Neighbour – please specify): If alleged abuser already known to social care, please provide CLIX/Frameworki Number: Is the alleged abuser a vulnerable adult? Yes No

NB: If the alleged abuser is a vulnerable adult, a separate referral is needed from team management

Details of Alleged Abusers’ Relationship with Organisations and other Vulnerable Adults
It is important that you provide the following information when you know the alleged abuser has contact with other vulnerable people – through working, volunteering, as a service user, relative etc Please complete this when the allegation is about a service, or the alleged abuser has contact with an organisation
Service Provider Address: Contact Name:

Title: Post Code: Tel:

Relationship of alleged abuser (tick as appropriate):
Main family carer Please specify relationship : Staff member Relative Please specify relationship: Service User

Other (eg: Friend, Professional, Volunteer, Neighbour – please specify):

Details of Person making the Referral
Please tell us the first person who raised this concern, and then informed WM Police/Adult Social Care/ Mental Health Teams or CSCI . We would try to respect any referrer’s wish for
anonymity but this might not be possible, with a serious allegation they might be required to provide witness evidence

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Title: Forename: Address – own address or employers, the best pace to contact you: Post Code: Relationship to Person Being Safeguarded: Date reported: How reported: Personally Telephone Other (please specify) Tel:

Surname:

Time reported:

Fax

Email

The information in this box is needed, only when relevant to the referral Occupation: Employer:

Person completing this form
If this is the same person as the referee please indicate Yes You will not need to complete this information twice Title: Forename: Address – own address or employers, the best pace to contact you: No Surname:

Post Code: Relationship to Person Being Safeguarded:

Tel:

Consent and Confidentiality
Has the referral been discussed with the Person Being Safeguarded? If yes, who by? If not, why not? Does the Person Being Safeguarded understand why you want to make the referral? Has the Person Being Safeguarded given permission for your concerns and details of the alleged abuser to be shared ? Yes If No – give reasons for proceeding without consent. No Yes No

Yes N/A

No

Team Manager completion
Initial referral made to: Police Adult Social Services/PCT CSCI

Name: Rank/Position: When the incident involves a Registered Agency, the Team must notify the following: Commission for Social Care Inspection. Whom did you notify when?  Contract and Commissioning Team Whom did you notify when? Could any children be at risk? No Yes (if yes, Team Manager must notify the Children Team Whom did you notify when?

ASC/PCT Responsible Manager
Please sign that you have checked that there is sufficient content on this referral for it to be logged on FWI Name: Date: Signature – for post and faxed copies:

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Thank you for this referral
It will be dealt with as a matter of priority.

Hereford Hospitals NHS Trust: If you work here and you are referring a patient please send
this form to the:  Hospital Social Work Team – Tel: 01432 364072 (internally – ext 4072) Fax: 01432 364038

Otherwise please send this form to your nearest Customer Services Officer or Specialist
Team from the list below, at Hereford Council Adult Social Care Teams or the Hereford Primary Care Trust.  East Team – Swan House, Edde Cross Street, Ross on Wye, HR9 7BZ Tel: 01432 383251 Fax: 01432 383268  West Team – The Old Priory, Leominster, HR6 8EQ, Tel: 01432 383349 Fax: 01568 610147  City Team – Bath Street, Hereford, HR1 2HQ Tel: 01432 261627 Fax: 01432 261718  Learning Disability Team – Hillrise, Southbank Road, Hereford, HR1 2RT Tel: 01432 373200 Fax: 01432 373227  Adult Mental Health Team – Monkmoor Court, 31-34 Commercial Road, Hereford HR1 2BG Tel: 01432 361600 Fax: 01432 361640


Mental Health Older People – Monkmoor Court, 31-34 Commercial Road, Hereford, HR1 2BG Tel: 01432 361600 Fax: 01432 361651

 Out of hours Emergency Team - Tel: 01905 768020  Police Public Protection Unit – Hereford Police Tel: 01432 347393 Fax: 01432 267032

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