CONFIDENTIAL
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Appendix 4 (form 75)
Multi-Agency Safeguarding Adults Referral Form
This form is only to be used when abuse of an adult has been discovered, suspected or disclosed
Please complete this form with as much factual detail as possible and include any allegations that are made.
This form might be used in future criminal or civil proceedings and accuracy is therefore vital.
Details about the Adult in need of care and support:
Name:
Date of Birth:
Age:
Gender: Male
Female
Address:
Telephone no.
If not currently at the above address, where can the Adult be contacted?
Why is the Adult in need of care and support?
Mental Health
Dementia
Visual Impairment
Aspergers/Autistic SD
Learning Disability
Older Person
Hearing Impairment
Physical Disability
Terminal Illness
Dual Sensory Loss
Frailty/Temp Illness
Head Injury
Substance Misuse
Additional Information if any:
Name of GP, Care manager, Health worker (please include telephone number(s)):
Ethnicity & Diversity:
White:
White British
White Irish
Any other White Background
Traveller of Irish Heritage
Asian or Asian British:
Indian
Pakistani
Bangladeshi
Any other Asian background
Mixed:
White & Black Caribbean
White & Black African
White Asian
Any other Mixed background
Other Ethnic Group:
Chinese
Any other ethnic group
Any other relevant diversity issues (e.g. religion, sexuality):
Who is making the alert:
Name:
Relationship to the Adult?
Address:
Telephone No.
Preferred means of contact: Who
is filling in this form?
Organisation:
Black or Black British:
Caribbean
African
Any other Black background
Not Stated:
Refused
Information not yet obtained
Is the alleged victim aware that this alert has been raised?
Yes
No
Is their next of kin/family carer aware this alert has been raised?
Yes
No
Details of the Suspect:
Relationship to the Adult at Risk?
Name:
Address (if different to the Adult in need of care and support):
Yes
Is this person a family or main carer (if known i.e. not care staff)?
No
Nature of the Allegation:
Where the alleged abuse took place:
Own Home
Care Home
Hospital
Day Centre/Service
Public Place
Other, please state:
Alleged Perpetrators Home
Care Home with Nursing
Mental Health Inpatient Setting
Education/Workplace/Training
Private Hospital
Supported Accommodation
Respite/Short-term break Home
Other Health Setting
Custodial situation
Not Known
NAME OF ESTABLISHMENT (if applicable)
Date the alleged abuse took place:
Type of abuse:
Physical
Self-neglect
Time:
Sexual
Neglect
Other , Please state:
Organisational
Financial
Psychological/Emotional
Brief details of what has been alleged to have taken place:
(Please include as much relevant information as possible to enable a decision to be made)
Is domestic abuse suspected?
Yes
No
Are there any child safeguarding issues?
Yes
No
Signature:
Print Name:
Date:
For further information please visit the Adult Safeguarding Webpage
(please ensure you save this form before using the link)