Safeguarding Referral

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Crew 1 Crew 1 Role Crew 2 Clinical Role Incident Time Incident Date Incident Number/Daily Cad Number Referral for Person being referred full name Person being referred D.O.B Person being referred home address Person being referred phone number What is your concern? Please provide as much detail as possible. Did you gain consent for this referral? Did person being referred have capacity?
Category of abuse
Self Neglect (including suicide)
Neglect
Care Concern - Social Care Provider
Discrimination Abuse
Domestic Abuse & Violence
Emotional Abuse
Financial Abuse
Organisational Abuse
Physical Abuse
Sexual Abuse
Child Abuse or Child Sexual Exploitation (or risk of)
Female Genital Mutilation (or risk of)
Modern Day Slavery
Prevent (radicalisation or risk of)
Child Death/​Poor Prognosis
Under 18: Intentional Overdose/​Self-Harm
Under 18: Intoxicated/​Illicit Drug Use
Home Situation Relevant Medical History - physical disability? Person has a Learning Disability? History of Mental or Emotional Illness? Any Risk Behaviours Identified? Any Domestic Violence and Assault Concerns? House Clutter Rating Who was on scene (police, fire, social services etc) Social Services on Scene? Police on Scene? Last Known Location of the Person being Referred Submit