Adult Safeguarding Referral Form

In an emergency call 999

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Where possible this should be completed by the person making the original referral. If you are having difficulty completing this form telephone Customer First 0808 800 4005

If you need to speak to the out of hours Emergency Duty Social Work Service call 01473 299669 (6.00pm to 8.00am)

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Page 1. Information about the person being referred

Fields marked with an * must be completed. The ? button provides extra help where appropriate

Name *

Please enter then name of the adult being referred. Enter 'unknown' if you don't know the name. Please fill in as much of the personal information as you have available. Click on the '?' again to hide this message.

Gender * Male Female

Address

Victim Care Centre Responsible Rowan House - Bury Conifer House - Ipswich The Beeches - Lowestoft

This question refers to the area where the victim lives and helps to direct the referral to the correct Adult Safeguarding Manager. If the victim lives in the Bury St Edmunds area click Rowan house, if they live in the Ipswich area click Conifer house and if they are in the Lowestoft area click The Beeches. If unsure please check the area map (360kb PDF, opens in a new window). Click on the '?' again to hide this message.

Age and Dob

Contact details

Police CIS/Polaris/Compass number


Ethnicity White/British White/Irish White/Other White & Black Caribbean
White & Black African White & Asian Any other mixed background Asian/Indian Asian/Pakistani Asian/Bangladeshi Any other Asian background Black African
Black Caribbean Any other Black Background Chinese Any other Not known

First Language

Interpreter required

Interpreter details

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Fields marked with an * must be completed. The ? button provides extra help where appropriate

Page 2. Information about the referral

Does the person know a referral is being made? Yes No


Details

Please tell us what the views are of the person about this referral, or why they haven't been informed.

Does anyone else know a referral is being made? Yes No


Details

Does the alleged abuser know a referral is being made? * Yes No


Customer Group Older Person Physical Disability Learning Disability
Mental Health Sensory Impairment Other


Type of abuse * Physical Sexual Financial Neglect Emotional Self Neglect Other


Place of abuse Day Service Work/College Public place Other

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Fields marked with an * must be completed.

Page 3. Referrer's Details

Name

Referrer role/relationship to victim


Referrer address

Referrer email

If you provide us with your email address we will send a confirmatioin email containing this referral to you.

Re-enter email

Telephone - landline

Telephone - mobile

Appropriate time to call

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Page 4. Details of alleged abuser/suspect

Fields marked with an * must be completed.

Full name

Address

Relationship to victim

Age/Dob

Police/Social worker contact

Date/time/location of the incident

Reason for concern

Form completed | Review and submit

Review and submit your referral

Please take a second to review the information you entered. Click the back button to return to the form to make any changes.