Safeguarding Concern Form – Get Me Out The 4 Walls

Please complete this form as soon as possible, preferably within 24 hours.

If a child or vulnerable adult is in immediate danger, please phone 999.

All information will be treated as confidential and managed in accordance with relevant data protection legislation and guidance. You have a right of access to information held on you under the Data Protection Act 1998.

Safeguarding Concern Form

Your Details - Full Name:

Contact Email Address:

Contact Phone Number:

Do you know the person at risk?

Name of person at risk

Gender

DOB/Age (If Known)

Contact Telephone Number

Email Address

Address

If under the age of 18, please record the details of person with parental responsibility

Parent's Name

Parent's Contact Number

Parent's Email Address

Details of concern

Are there any other services involved with your person at risk?

Declaration

Does the person at risk agree to you making the referral to us?

Yes

If no, Why did you feel it was not appropriate to advise the person that you were making a referral to us.

I confirm that the above information is supplied to the best of my knowledge

Signed

Date Completed