Report a safeguarding concern
Referrer Details
Mandatory - Name of worker completing referral
Mandatory - Job title
Invalid - Email address
Mandatory - Agency/Provider Name, Address and Phone number
Details of Person with Care and Support Needs
Mandatory - Their first name
Mandatory - Their last name
Invalid Date - Date of birthMandatory - Date of birth
Mandatory - Address
Mandatory - Postcode
Concern
Mandatory - Can you please provide details of what happened considering relevant circumstances or changes leading up to the event
Mandatory - What was the impact upon the individual? For example any physical injuries or emotional distress
Mandatory - When did it happen?
Mandatory - Where did it happen?
Mandatory - Who was involved?
Mandatory - Were there any witnesses?
Mandatory - What measures have been taken following the incident? For example CQC notification, police involvement or a change in staffing relationships
Mandatory - In your opinion is the person now safe?
Persons views
Mandatory - Does the adult with care and support needs know this concern is being raised?
Health and social care services
Form submission
Please tick the confirmation box and click on the ‘Submit Form’ button below when you have completed this referral form with all the information and details available to you. Only then will this form be sent securely to Adult Social Services.
Following this you will shortly receive an email at the email address you entered above in the Referrer Details section, confirming this referral form has been sent to Adult Social Services.
Once your form has been received the information you have supplied will be used to help us investigate your concern. In the course of our investigation it may be necessary to share your details with partner organisations such as the Police.
It may be necessary for us or our partners to contact you using the details you have provided if we require further information.
If you do not receive this automated confirmation email the referral form may not have been completed and therefore not sent to Adult Social Services. Please ensure you have ticked the confirmation box and clicked on ‘Submit Form’ before exiting this form as it will not save the information.
Mandatory - I confirm that this referral form is now completed and ready to be sent to Adult Social Services.
Data Protection
Your information may be shared with other council services and partner organisations to ensure
our records are kept accurate and to help us to identify services or benefits you may be entitled to or interested in.
We may also need to share your information for the prevention and detection of fraud and/or other crimes or as the law requires.
For further information about how we use your information please refer to the Council’s Privacy Statement on
www.solihull.gov.uk.