Safeguarding Form

This form is to be used by any Counsellor or member of the Therapy Centre Services team to record disclosures or suspicions of suicidal ideations/suicidal intent, abuse or other concerns where safeguarding is required.

You full name and initials

Your position

Location

Your phone number

Client address

Client full name

Client phone number

Client date of birth (if known)

Month

Day

Year

Client is:

CHILD

ADULT

Name of Client GP & practice contact number

Other relevant details about the client : e.g. family circumstances, physical and mental health, communication difficulties

Details of the safeguarding concerns/allegations/suspicions:

Are you recording

Disclosure made directly to you by the client

Disclosure or suspicions by a 3rd party

Your own suspicions or concerns

Date and time of disclosure

Month

Day

Year

Time

Date and time of incident (if applicable)

Month

Day

Year

Time

Details of the safeguarding concerns/allegations/suspicions. State exactly what you were told/observed and what was said. Use the persons own words as much as possible

Actions taken so far

Next step/action

Date to be actioned

By whom

Signed

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Safeguarding Form

You full name and initials

Your position

Location

Your phone number

Client address

Client full name

Client phone number

Client date of birth (if known)

Month

Day

Year

Client is:

CHILD

ADULT

Name of Client GP & practice contact number

Other relevant details about the client : e.g. family circumstances, physical and mental health, communication difficulties

Details of the safeguarding concerns/allegations/suspicions:

Are you recording

Disclosure made directly to you by the client

Disclosure or suspicions by a 3rd party

Your own suspicions or concerns

Date and time of disclosure

Month

Day

Year

Time

Date and time of incident (if applicable)

Month

Day

Year

Time

Details of the safeguarding concerns/allegations/suspicions. State exactly what you were told/observed and what was said. Use the persons own words as much as possible

Actions taken so far

Next step/action

Date to be actioned

By whom

Signed

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.