Concern Form
For reporting any concerns for the wellbeing or the abuse of a young person. It is recommended that you speak to an Exodus Area Leader or Designated Safeguarding Officer before completing.
Person Reporting
Your Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Mobile Number
*
Please enter a valid phone number.
Format: 000 000 00000.
Your Local Area
*
Please Select
Banbridge
Belfast
East Antrim
Lisburn
MidUlster
North East (Coleraine)
North West (Derry & Donegal)
Role
*
i.e. Mentor / team leader or coworker / staff member / participant
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Person at Risk
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Age
*
Under 18
18 or over
Unknown
Next of Kin Details (if known)
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Nature Of The Concern
This helps us identify the best person in our team to talk to.
Does the concern for the named person above relate to;
*
Wellbeing (including their mental health, mood, thoughts of harm)
Abuse (Disclosures, allegations or potential signs of abuse)
When did your concern for the individual first arise?
*
-
Month
-
Day
Year
Date
Where were you when your concern for the individual first arose?
*
eg a drop in in Exodus Lisburn / team 99 team meeting
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Concern for Wellbeing
including mental health, mood, thoughts of harm
Please summarise your concern in a sentence
*
Give details of your conversation or observations that led to this concern
*
Who Else was Present (if any)?
*
What immediate action was taken?
*
Have you spoken to the Exodus Local Area Leader?
*
Yes
No
What actions were agreed (with deadlines)?
*
Any Additional Comments
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Concern of Abuse
Disclosures, allegations or potential signs of abuse
What best describes this situation?
*
Disclosure (from the named individual)
Allegation (from someone else involving the named individual)
Potential signs of abuse (noted by you or others)
Who else was present (if any)?
*
Give a brief summary of anything you heard from the named individual or others, that relates to your concern
*
What did the individual(s) actually say?
Describe any signs or potential indicators of abuse that were observed (if present)
*
If none observed, please write none.
Did the named person (or another individual) indicate that any particular person is the abuser?
*
If yes, please record as many details here as possible incl name and relationship to the named person. If no, type no
What immediate action was taken?
*
Have you spoken to an Exodus Designated Officer?
*
Yes
No
What actions were agreed (with deadlines)?
*
Any Additional Comments
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To the best of my knowledge the information I've given is accurate
*
Submit
Submit
Should be Empty: