/ External Request Form
Concern_Welfare Check (ERF010)

The details contained in this form are subject to both the Data Protection and Human Rights Acts and as such, once any information has been entered into the form it is RESTRICTED. Consider storage, printing implications and use only secure email network facilities. You are responsible for compliance with legislation.

Part A - to be completed by applicant

Applicant details
Organisation:
Address:
Name: / Position: / --- please select ---Police StaffPSEPC/DCPS/DSInsp/D InspC Insp/DCISupt/D SuptChief SuptOther / Force/ID
Number:
Job title:
Email: / Mobile: / and/or
Telephone:
Investigating Officer details(as above? )
Name: / Position: / --- please select ---Police StaffPSEPC/DCPS/DSInsp/D InspC Insp/DCISupt/D SuptChief SuptOther- please select - / Force/ID
Number:
Job title:
Email: / Mobile: / and/or
Telephone:
Subject Details
Name: / DOB: / Sex: / --- please select ---MaleFemaleOther
Address:
Postcode:

Part B – Request for

***Kent police will only ... the OIC cannot do this themselves***
When, where and in what circumstances was the subject last seen or contact made?
Describe what efforts have been made to locate, contact or retake the subject.
Address Visited? / --- please select ---YESNO
If YES result of visit
Telephone contact attempted? / --- please select ---YESNO
Detail of number(s)
If YES to above, what was the result?
Have Next of Kin been informed? / --- please select ---YESNO
Details of N.O.K/Emergency Contact:
Name
Relationship
Address
Contact number
Please note:
It is expected that your agency will have undertaken reasonable enquiries to resolve the concern raised.Whilst Kent Police appreciates that efforts made by your agency to address the concern may be affected byyour resource availability on occasions, this is unlikely to have an impact on our assessment of your request.Where insufficient efforts have been made, the request will be declined and the form returnedto you, using the contact details provided.
Other address(s) where subject might be and reason for believing this person will be at this address or relationship of address to the individual:
Risks associated with the subject - please define and record currency of evidence:
Risk of harm to self (e.g. deliberate self-harm/ suicide/ self-neglect) / --- please select ---YESNO
Details
Risk of harm to others (e.g. homicide/violence/aggression) / --- please select ---YESNO
Details
Risk of harm to children/vulnerable adults (either through acts of omission or commission) / --- please select ---YESNO
Details
Recommended advice for engaging with the subject:
Details of court order, Mental Health Act order and Mental Health Act status relevant to the subject.
Relevant Kent Police reference numbers or previous calls:
State the rationale for your request and why the police are specifically being asked to attend:
Please note:
An on-going general concern relating to an individual's mental health will not ordinarily necessitate policeinvolvement.
Are you to be contacted with result/update? / --- please select ---YESNO
If no please supply details of contact:

Please attach and send your completed request to