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Concerns for Vulnerable Adult/Child’s Wellbeing
This form should be completed by workers and/or volunteers of Comas wishing to share their concerns
about a vulnerable adult, pregnant mother, a baby, child or young person. The concern is shared with
your line manager. If you have any concerns that a vulnerable adult, baby, child or young person may
be or is at risk of significant harm or has been harmed or abused then you must ensure that the
Designated Member of Staff is aware of your concerns and immediate action is taken. Contact details
for Designated Member of Staff, Social Care Direct (social work) and Public Protection (police) can be
found at the end of this form.
Please note: A vulnerable adult is an adult who may be at risk, they might include people over 16 who:
find it difficult to keep themselves or their property (their home, the things they own) safe; might be
harmed by other people; might be more vulnerable because of a disability, illness or mental disorder
(this could mean people with mental health problems, people with dementia, people with learning
disabilities). It doesn’t mean that all people with learning disabilities, mental health problems or
illnesses or disabled people are always ‘at risk’.
Identifying details
Record details of vulnerable adult, pregnant mother, baby, child or young person being referred. If it is a
pregnant mother, state name as ‘unborn baby’ and mother’s name, e.g. unborn baby of Mary McDonald
First
Name(s)
Male
Last Names
Female
Unknown
Address
AKA1/pre ious
names
Date of birth or
EDD2
Contact tel. no.
Mobile no.
Other no.>
Postcode
Details about child’s or vulnerable adult’s family
Parent’s or carers’
first language
Child’s or vulnerable
adult’s mother
Child and Vulnerable Adult Form v2 CMG 13.10.15
Child’s or vulnerable
adult’s father
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Is the child or young person
disabled?
No
Yes
If ‘yes’ give details
Details of any special requirements
(for child a d/or their parent) eg
signing, interpretation or access
needs
About the vulnerable adult’s immediate family (who they live with or their parent, sibling) – if
appropriate
First
Name(s)
Male
Last Names
Female
Unknown
Address
AKA1/previous
names
Date of birth
Contact tel. no.
Mobile no.
Other no.>
Postcode
What action have you taken?
(What have you done to help? Offer support? Who have you told?)
If you are the Designated Member of Staff or Line Manager how have you responded? Please record your
response and the response of others your shared your concerns with – please date actions taken.
Child and Vulnerable Adult Form v2 CMG 13.10.15
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Details of parents/carers
Name
Contact tel.
no.
Relationship to vulnerable adult, unborn baby,
infant, child or young person
Address
Parental responsibility?
Yes
No
Postcode:
Relationship to vulnerable adult, unborn baby,
infant, child or young person
Name
Contac tel.
no.
Address
Parental Responsibility?
Yes
No
Postcode:
Child and Vulnerable Adult Form v2 CMG 13.10.15
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Details of person(s) sharing the concern
Name
Contact tel.
no.
Address
Role
Organisation
Postcode:
Name of lead professional (where
applicable)
Lead professional’s contact number
Lead professional’s email address
Other services
Universal
Services working with this vulnerable adult, pregnant mother, baby, child or young person
GP
Details
Tel.
Early years/education
Details
Tel.
Service
Details
Tel.
Service
Details
Tel.
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Vulnerable adult, Child or young person’s comment on the referral and current circumstances
Parent or carer’s comment on the referral and current circumstances
Information Sharing
Has the parent/carer consented to you sharing your concerns with the Named Person, CPN, GP
another agency and/or making a referral to social care direct Yes
No
Has the young person (over 12) consented to you sharing information about them Yes
Has the vulnerable adult consented to you sharing information about them Yes
No
No
Please read the following:
Parental consent to share information must be sought before a referral to a Named Person,
agency or Social Care Direct, unless not to do so would place a child or young person at increased
risk of significant harm, or place an adult at risk of serious harm.
Consent from the vulnerable adult must be given before a referral to social care direct or
contacting their GP or CPN (or other relevant agency), unless not to do so would place the
vulnerable adult at increased risk of significant harm, or place you or someone else at risk of
significant harm.
Designated Member of Staff/Line Manager signature
Signed
Name
Date
Where to send this form
Please give this form to your line manager/Designated Member of Staff. If you have any concerns
that a vulnerable adult, baby, child or young person may be or is at risk of significant harm or has
been harmed or abused then you must ensure that the Designated Member of Staff is aware of
your concerns and immediate action is taken.
Child and Vulnerable Adult Form v2 CMG 13.10.15
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Child and Vulnerable Adults Protection Contacts
COMAS
Designated Member of Staff – Ruth Campbell (Chief Executive Officer) – 07980 844350
ruth@comas.org.uk. Catriona Grant (Women in Recovery Manager) – 07717 204426
catriona@comas.org.uk
Line Managers – Caitlin Rodgers (Cafe Manager – Serenity Café) - caitlin@comas.org.uk
Catriona Grant (Women in Recovery Manager – Woman Zone) – 07717 204426
catriona@comas.org.uk
Louise Cowie (Senior Project Manager – 20 More) – Louise@comas.org.uk – 07742
580400
Zosia Ross (Senior Project Worker – Best Days) – zosia@comas.org.uk – 0784 188539
Social
Care
Direct:
Social Care Direct – 0131 200 2324 socialcaredirect@edinburgh.gov.uk
Emergency Social Work Service: 0800 731 6969
Police:
Public Protection Team – 101, ask to speak to Public Protection Team at Fettes,
Edinburgh
Child and Vulnerable Adult Form v2 CMG 13.10.15