Concerned about an adult in York? Let us know

Raise a concern - professionals form

Before you begin

As a professional completing this form you must provide detailed information, some of which is 'required', meaning you can't continue the form without it. Therefore we recommend you gather and/or consider the following before you begin:

the Mosaic ID and NHS Number for the person for whom you have concerns (if known)
title, name, alisases, and address (including postcode), telephone number and email address of person for whom you have concerns
the date of birth, gender and ethnicity of person for whom you have concerns
whether the person has any special communication needs, the nature of those needs and their preferred communication method, including Preferred language and an interpreter is needed
whether the person has care and support needs, the primary reason for care and support, and details of the services they receive including who commissions the primary service and the deatils of professionals working with the person (name, organisation and contact details)
whether the person is aware of the concern and that you're raising it, or why you're raising a concern while they are not aware
whether the person has mental capacity to make decisions to safeguard themselves, or to accept support in relation to the outlined harm or potential harm
whether the person has support from a friend, relative, representative or formal advocate, and details of the support
whether the person expressed any views or wishes about safeguarding intervention and details of their views
details of your concern, including the date, type of abuse, and location of incident
details of any injury, including description and copy of a completed body map
whether the person continues to be at risk of harm or there an emerging pattern of abuse?
details of any witness to the incident (name, contact details)
if any other professionals or agencies are aware of the concern, including their details
an outline action taken to protect the individual and others
whether the Police have been informed (where a crime is suspected), including a Crime Reference Number
whether any medical attention has been sought, and details of the medical attention sought
if anyone else is at risk of harm
whether Childrens' Services need to be informed, and details of which service
whether the person you're concerned about a carer for another adult or child, and details of their role
the Mosaic ID and NHS Number (if known) of the Person Alleged To Have Caused Harm (PATCH)
the title, name, alias, address (including postcode), telephone number and email address of the PATCH
the date of birth, gender and ethnicity of the PATCH
whether the PATCH is they aware of the concern being raised
the views of the PATCH on the concern being raised
the relationship of the PATCH to the person of your concern
what organisation the PATCH works for
whether the PATCH is the main carer of the person of your concern
whether the PATCH lives with the person of your concern
whether there are any other people at potential risk from the PATCH, and details about who else is at risk
whether the PATCH would pose a risk to anyone visiting the person they are allegedly harming, and details about the potential risk
if the PATCH is someone who also has support and care needs
if the PATCH is known to the council
your own contact details (name, aliases, organisation, telephone number and email address)
whether you're happy for these to be shared with third parties (or your reasons for wanting to remain anonymous)