1. About you the referrer
Date of Referral:
Name of Referrer:
Referrers Job title:
Referrers Organisation:
Referrers phone number:
Referrers email address:
2. If you are seeking advice, please outline the nature of the advice you are seeking:
3. About the Person in a Position of Trust
Full name:
Date of Birth/Age:
Gender:
Home address (if known):
Phone number (if known):
Is this person aware of this referral?
4. What role does the Person in a Position of Trust have, that raises concerns:
Job title/Role:
Outline of their responsibilities:
Please outline the care and support needs of people they support:
Details of the employer / volunteer organisation / student body
Organisation name
Organisation’s address
Organisation’s phone number
If the person has more than one position of concern; please tell us about the others too:
5. What are the risks to adults with care and support needs:
What is the evidence for these risks to adults with care and support needs?
What has happened?
How do you know this?
Was someone harmed? Who? How?
When did this happen?
Was there some form of investigation?
Were the police informed?
6. Risks to children
Is there a risk to any child?
What is the risk and to whom?
Have you informed the LADO?
7. What (if any) actions have already been taken, in relation to the risk posed by the person in a position of trust?