London Borough Of Hackney HSC 1 Hillman Street Hackney

London Borough Of Hackney HSC 1 Hillman Street Hackney

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London Borough of Hackney
HSC ,1 Hillman street, Hackney E8 1DY
Telephone: 020 8356 5782
Safeguarding Adults Alert/Referral Form
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Referral Guidelines
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1.
Fields marked * must be completed
2.
The filled in form must be sent to [email protected]
or faxed to 020 8356 5043
3.
You have to fill in the form electronically, save, print and fax
or send by email ( please don’t fill in by opening from the email)
4.
Where a criminal act may have committed the police must be
notified immediately on 999 in an emergency or on 101 in other
cases
5.
To fill dropdown options click and choose an item or type in if
different from the list
Personal Details of the adult at risk*
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Title
Choose one or enter
Today’s date
Enter by clicking
First Name
Surname
Social Care ID
NHS number
Date of Birth:
Gender:
Choose an item.
Ethnicity:
Religion:
Practicing
Choose an item.
Current Address
Sexual Orientation
Choose an item.
Tenure Type
House hold structure
Phone numbers
Email:
Post Code:
Preferred method of contact
Preferred Language:
Fluency in English
Interpreter required
Communication support required
If Yes Further details:
Advocate required
Choose an item.
If Yes Name of advocate
Does the person have recourse to public funds
Choose an item.
Further details
Employment status(current)
Start date
Marital Status
Choose an item.
End date
Next of Kin
Choose an item.
If Yes relationship
Name
Address
Telephone (Home)
Mobile
Support from informal carer
Choose an item.
If Yes Name of carer
Address
Relationship
Telephone number
Name of GP
Name of Practice
Address
Telephone number
Accommodation status
Choose an item.
Lives with
Is the carer aware of this alert
Choose an item.
Is this person known to Local Authority?
Choose an item.
If not why not?
Is this person in a placement
Choose an item.
If Yes, placement details. Name of Local Authority
If this person a self-funder in any way
Choose an item.
Funded by
If Yes, please specify
Referral Details*
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Name of referrer
Referral date*
Relationship
Role
Name of organisation
Address
Telephone number
Mobile
Is the client aware of this referral
Choose an item.
Referral method
Referral type (from contact)
Diagnosed Health condition
Primary Support Reason
Location of alleged abuse
Choose an item.
Location at the time of referral
Details of the incident ( give a summary of the alleged abuse)
Mental Capacity*
----------------
Does the adult at risk have mental capacity to consent to this
referral
Choose an item.
If No has capacity assessment arranged
Has the adult at risk given consent for this referral and share
information
Choose an item.
If No please state the reason why
Has advocacy been offered as a result of this alert?
Choose an item.
Is there already an Advocate/IMCA in place?
Choose an item.
If Yes, name of advocate/IMCA
Details of Alert/Referral*
--------------------------
Type of alleged abuse(main)
Choose an item.
Type of alleged abuse(any other)
Choose an item.
Date of incident*
Location of incident
Choose an item.
What category of Crime does the abuse fall under
Choose an item.
Please specify the nature of crime
Any other adult at risk in the house hold
Name
Date of Birth
Have separate alerts been raised
Choose an item.
If more than one enter the names here
Information about involvement of others
Name
Role
Telephone number
Mobile
Name
Role
Telephone number
Mobile
Name
Role
Telephone number
Mobile
Information about Person alleged to be causing harm*
Name
Date of Birth
Address
Telephone number
Email:
Gender
Ethnicity
Relationship with the adult at risk
Choose an item.
If professional specify
Was the alleged person causing harm living with the adult at risk at
the time?
Choose an item.
Are they still living with the adult at risk
Choose an item.
Questions to adult at risk and the outcomes the person may want to
achieve from safeguarding.
( Discuss and encourage the person to consider their top 3 outcomes
from the drop down list)
Thinking of your current situation how safe do you feel
Choose an item.
What do you want to happen-1st choice
Choose an item
What do you want to happen-2nd choice
Choose an item.
What do you want to happen-3rd choice
Choose an item.
How would you like to be kept up to date and informed about what
happens now?
Details of Action taken
-----------------------
Who have you contacted in relation to this incident?
Name
Job title
Organisation
Telephone number
Action taken to protect the adult at risk
Have police been notified
Choose an item.
If Yes crime reference number
Is the adult at risk willing to assist in a criminal investigation
Choose an item.
If No, is there a public interest in carrying out an investigation
(e.g. other people are at risk)?
Choose an item.
Medical attention given
Choose an item.
If Yes, name of hospital
Name of Doctor
Details of the person completing this form
Name
Job title
Contact details
Date
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