Confidential incident/concern form

All fields marked with an asterix require a response. If this field is not applicable to your circumstances, please just respond 'Not applicable'.

Name of person reporting the incident *

Church role

(Mobile) telephone number *

Email address *

Date

Name and contact details of child/young person/adults experiencing or at risk of experiencing abuse or neglect.

Is person experiencing or at risk of experiencing abuse or neglect under 18?

Does the person experiencing, or at risk of, abuse/neglect have any mental health issues?

Contact details of person experiencing, or at risk of, abuse or neglect

Name and contact details of parent/guardian/carer of person experiencing, or at risk of, abuse/ neglect (if applicable)

Position and church of person causing concern *

Nature of concern (the allegation, behaviour or risk) *

Date/time of occurence/incident *

Location of occurence/incident *

Who have you spoken to about your concerns? Tick all that apply *

Child/person/adult experiencing

or at risk of

abuse or neglect

Their parent/guardian/carer

Senior staff/line manager

Social Services

Police

Probation

Other

* Required Fields