Adult Support and Welfare Concern Form

This form should be used to submit concerns for individuals over the age of 16 who you know or suspect to be at risk of harm. Please provide as much information as possible about the individual and the circumstances surrounding your concern.

With the information you provide, West Lothian Council may make inquiries underpinned by The Adult Support and Protection (Scotland) Act of 2007 to establish if further action is required to assist in the prevention of harm.

Please note, one form needs to be completed for each individual at risk.
Label
1. Person submitting the details
  1. In order for us to process an Adult Protection and Welfare Concern referral we require your name and contact number at minimum. West Lothian Council may use your information to contact you regarding this referral, however the person you are referring will not be made aware of your details.
  2. Name
  3. Your address
    
    Your Address
    
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    Your Address
    
    OSG Postcode Search (Custom drop-down list)
    
    Postcode
    
    Address
  4. Contact Number
  5. Email Address
  6. Relationship to adult
Adult's Details
1. Please provide as much information as possible within this section to assist us with making inquiries.
2. Full Name
3. Date of Birth (if known)
  
  Day
  
  Month
  
  Year
4. Party ID Number (if known)
5. Your address
  1. Address (if known)
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  3. Your Address
    
    OSG Postcode Search (Custom drop-down list)
    
    Postcode
    
    Address
6. Contact Number (Please ensure this is a safe number for us to call)
7. If the contact number does not belong to the adult concerned, please advise.
8. Gender
9. Does the adult have any communication needs? For example, a hearing impairment or requires an interpreter.
  
  Yes
  
  No
10. Please provide details
11. - Office of the Public Guardian
12. Is there welfare guardianship in place?
  
  Yes
  
  No
  
  Unsure
13. Please specify by providing details.
14. Is there a Power of Attorney in place?
  
  Yes
  
  No
  
  Unsure
15. Please specify by providing details.
‘Adult Protection Referral’ should be selected if you know or suspect that there is a risk of harm to an adult who is ‘an adult at risk’ as defined by the Adult Support and Protection (Scotland) Act 2007. This definition includes people aged 16 and over with disabilities and/or mental health disorders, illness, or physical or mental infirmity who are unable to safeguard themselves and who are at risk of harm from themselves or others.

‘Welfare Concern’ should be selected if you have concerns about an adult but they are not ‘an adult at risk’ under the Adult Support & Protection (Scotland) Act 2007.
Label
1. Adult Protection Referral
2. Welfare Concern
CONSENTWELFARE
1. We do not require consent for this referral, however if you have it, please advise as it will help with the enquiry.
2. Do you have consent from the adult concerned to submit this form?
  
  Yes
  
  No

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Your Address

Address (if known)