Police Use: URN: CRIS/PAC:
Date of Notification: Name of referrer:
Name: Care First or RIO ID:
Date of Birth: Ethnicity:
Gender:Male Female
Current Location:
Home Address:
Telephone Number:
GP Name and Practice Address:
DO NOT USE THIS NOTIFICATION FORM TO REPORT A CRIME.
IN EMERGENCY DIAL 999 or NON-EMERGENCY DIAL 101
Reason for Notifying Police: Information SharingRequesting Advice from Police SPOC
Intelligence Other:
Has a SA1 referral form been completed?: YesNo
Type of alleged abuse(please tick all that apply):
Sexual PhysicalNeglectFinancialInstitutional Discriminatory Psychological/Emotional
Concern(s) which has led to this notification including DATE, DAY, TIME & PLACE of any incidents, also if believed to be ongoing(please provide as much detail as possible):
Have there been any previous concerns about abuse in relation to this Service User? (please give full details if ‘YES’):
What are the Service Users vulnerabilities?(Physical, mental, learning disabilities etc):
Does Service User have mental capacity? YesNo Please specify details of Service User’s mental capacity to make decisions e.g. financial decisions:
Date of Assessments(if any):
Has consent been given to inform Police?: Yes No
Details
Are they known to the Referrer?: Yes No
How are the Risks being managed?:
Name:
Date of Birth:
Address:
Contact number:
Date of Birth: Address:
Contact number:
Name:
Date of Birth:
Address:
Contact number:
SSDHealth DeptMental Health TeamHospitalOther
Name:
Address:
Position:
Telephone Number: Fax Number:
Name:
Address:
Position:
Telephone Number: Fax Number:
Name of SAM:
Date Approved:
ONCE COMPLETE, PLEASE EMAIL THIS NOTIFICATION TO:
PY
Please ensure before you e-mail thisnotification, that all the relevant details are obtained and completed i.e. DOB’s, addresses, reference numbers etc. This information is required by police to conduct intelligence checks and for further investigation (if appropriate).
If you have any enquiries please call the Adults at Risk SPOC on 020 8284 8764 during Office hours (8am -4pm Mon-Friexcluding Bank Holidays)
For Out of Hours enquiries please call the Non-Emergency number on 101
Always dial 999 in an Emergency
FOR POLICE USE ONLY:
a) CRIS / Merlin Report ref number:
b) Information Sharing only (is there a legal gateway to share information?):
c) Strategy discussion between Police (Adult at Risk SPOC) and Referrer:
This information is sent in confidence and is restricted. It must not be passed on to a third party without the express permission of the police.
1
RESTRICTED
Adult at Risk Referral April 2015