Report a concern about a child

Please read before completing this form

If there are immediate concerns for a child a referral should be made immediately by telephone to the assessment service / duty team.
This form should then be completed and sent to the assessment team / duty team the same working day in accordance with all Wales Child Protection Procedures.
PLEASE NOTE: You may use this form to make a report at any time, but it will only be picked up by the team during office hours
Your details
1. First Name (Optional)
2. Surname (Optional)
3. Phone number (Optional)
4. Email (Optional)
Subject of referral (child, young person or unborn baby)
1. Name (Required)
2. Age (Optional)
3. Gender (Optional)
  
  Male
  
  Female
  
  Other
  
  Unknown
4. Address (Required)
5. Postcode (Optional)
6. NATURE OF CONCERNS: (including how and why those concerns have arisen) (Required)
7. Offensive terms within reports will be blocked and will not be received by us, these words can be masked using asterisks for example which will get through the filters.

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