Safeguarding Concern and/or Disclosure Form

Client's name
Name of person or professional raising concern
Name of person or professional submitting concern
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM
Care & Support Needs Eligibility

Do the client’s/individuals’ needs arise from a Physical or Psychological Impairment and/or illness? If yes, please provide as much detail as possible.
Care Act 2014- Section 42 or 47 criteria

Is the client/individual experiencing or at risk of abuse or neglect in one of the following categories?

Care Act 2014- Section 42 or 47 criteria

Is the client/individual experiencing or at risk of abuse or neglect in one of the following categories? Physical Sexual Psychological/emotional Financial/material Discriminatory Organisational/institutional Neglect or acts of omission Self-neglect/abuse Modern Slavery Domestic Abuse
Please provide details in relation to the above concern/ disclosure (what was observed, reported and/or disclosed by whom?)
Is the client/individual unable to protect themselves because of their care and support needs? (Please describe as a result of their care and support needs why they are unable to protect themselves).
Please describe what action you have taken following the concern/disclosure of abuse or neglect. (Please give details in relation to how the Safeguarding threshold has been applied and what action has been taken)
Please give details of any other relevant information
Please attach any relevant documentation to support the above (Daily records, Incident/accident report forms etc)

Attach Files
Signature of the person/professional submitting the above concern/disclosure:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.