Exceptional Risk Forum

Exceptional Risk Forum (ERF)

Alternative Plain Text Referral Form

If you find the the current Referral Form inaccessible. Please copy the questions from this page into an email, together with your responses and send to lsab.erf@leeds.gov.uk 

Exceptional Risk Forum: Referral Form

1. About the referrer: 

Name:     
Job title:     
Organisation:    
Email address:
Telephone:

1a. If your organisation has an ERF member, you need to agree the referral with them in the first instance.  This applies to A&H, ICB, LYPFT, LTHT, LCH, Forward Leeds and Housing Leeds. Has this been agreed?  Yes / No / NA

1b. All other organisations should agree the referral with their agency practice/safeguarding lead. Has this been agreed: Yes/No    

Name of agency lead:
Date of referral:    

2. About the person at risk:

Title:     
First Name(s):    
Surname:     
Date of Birth:
Age:
Address:
Post Code:

NHS Number (if known):    
Gender:    
Language spoken:    
Ethnicity:  

3. Referral checklist'

I have read and considered the 'Before you make a referral checklist'? Yes/No

4. Multi-agency agreement

I have discussed and agreed the need to make an ERF referral with other members of the multi-agency team and agreed appropriate representation. Yes / No

5. Brief high level outline of concerns

6. About the person’s circumstances:

6a. Information about the person at risk: Who are they? What is their history? What is their cultural background? What is important to them?

6b. Does the person have a physical or mental impairment or illness and as a result require assistance with aspects of their day-to-day living?  Please describe, including the impact these needs on the person and the risk they experience:

6c. Has the person experienced adverse childhood experiences or adult trauma that impacts on their ability to maintain their safety? Please describe:

6d. Summary of mental capacity issues. Has mental capacity been assumed? Has there been cause for it to be assessed? What was the outcome? And in relation to what decisions?

6e. Summary of the person’s views, wishes and desired outcomes in relation to the concerns

7. About risks:

7a. Risk Assessment: What are the current risks? And to whom? What are you concerned could happen?       How likely do you think this is? Have you attached a completed risk assessment?  Yes / No

8. About agency support and involvement. 

8a. Please provide a summary of services involved and support networks (include friends/relatives as appropriate)

8b. If a key agency is not involved, please explain why, and what has been done to gain their involvement.

8c. Summary of the person’s engagement with services?  If it has not been possible to engage effectively with the person, what are the reasons for this, what has been tried so far?

8d. Summary of multi-agency meetings held in relation to these concerns? If none held, why is this not possible?

8e. Summary of approaches undertaken and support offered/provided?

8f. Please comment on why it has not been possible to effectively mitigate risk? What are the barriers to addressing the risk?                              

9. About your request to the Forum:

9a. What advice are you seeking from the forum? 
9b. What outcome(s) are you aiming to achieve for the person at risk?