This form has 17 pages

You should complete this form in accordance with the Multiagency Policy and Procedure. Completing the form must not delay immediate action being taken where necessary to ensure the safety of the person you are concerned about.

Use this form to report an Safeguarding Adults Concern to Safeguarding Adults York.

Safeguarding Adults York believe that everyone has the right to live their life free from the experience, or risk of experiencing abuse and neglect, so they are able to maintain their own independence and wellbeing in York.

Before you complete this form if you think you need to contact Children's services about this issue - contact them now, you will be asked for this information later in the form.


In order to complete this form you may need to provide some or all of the following information:

  • The details of the person for whom you are concerned about
  • their current care and support needs
  • their consent, or reason for not having their consent
  • the details surround the concern and the concern itself
  • the details of those involved in the concern, if necessary

Please note: our system will 'time out' after 10 minutes. However, you will have 10 minutes to complete each page (not the overall form).

It is not possible to save partially completed forms, nor to retrieve information if the time out period is reached. For longer messages you may need to compose your feedback before starting this form. You can then 'paste' your text into this form once you're ready to send it.


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Please do not use this form to send anything of a confidential nature, for example your credit card or bank details.

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