Report a concern about a child

Please read before completing this form
1. 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. 1. First name
  2. Surname
2. Phone number
3. Email
Subject of referral (child, young person or unborn baby)
1. Name*
2. Age
3. Gender
4. Address*
5. Postcode
6. NATURE OF CONCERNS: (including how and why those concerns have arisen)*
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.
Declaration
1. Your declaration
  
  I understand the following:
  
  You will use the information I have provided to process my request / report.
  
  You will not share my information outside Powys County Council.
2. I understand the statement above and I declare that the information I have given on this form is correct and complete.*

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