Adult Safeguarding - Suffolk County Council

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Are you referring yourself?

Answer yes if you are completing this form for yourself, or no if it's for someone else

YesNo

Is the person you are contacting us about in immediate danger?

YesNo

Is your relationship with the person being referred of a professional or personal nature?

ProfessionalPersonal

What is your professional relationship?

What would best describe your relationship?

If other, please describe the relationship

Is the person you are contacting us about being harmed, abused or neglected or at risk of being so?

YesNo

Referrer

Title

Case type

Person referred