<p> CONFIDENTIAL Children's Services</p><p>LADO – Referral / Consultation Request form (to be completed by enquirer) </p><p>Referrer Contact Details: Name</p><p>Organisation</p><p>Position</p><p>Telephone number</p><p>Email Address</p><p>Referral? Y/N</p><p>Consultation Request? Y/N</p><p>For education settings, have you Y/N contacted the Education Intervention Service Duty Desk on 01603 307797? If the answer is no, please ensure that you contact them before sending this form into the LADO service.</p><p>Alleged Perpetrator Name</p><p>Address of individual concerned</p><p>DOB: (if known)</p><p>Ethnic Origin: (if known)</p><p>Known disability: (if known)</p><p>Alleged Perpetrators Information Working Sector</p><p>Name and address of work establishment: e.g. name of school, fostering agency etc (including voluntary establishments)</p><p>Occupation and job title</p><p>1 Details of any children resident at person’s home address? Name DOB Gender Relationship to alleged Perpetrator?</p><p>Does the person have any other contact with vulnerable individuals; please give details:</p><p>Any previous allegations /concerns, please give details?</p><p>2 Incident Details Details of alleged victim(s): Name Address DOB Gender Parent/Carers Name Address Legal Status</p><p>3 Person of interest demonstrated behaviour which is consider they have: Behaved in a way that has harmed a child or may have harmed a child Y/N</p><p>Possibly committed a criminal offence against or related to a child. Y/N</p><p>Acted towards a child(ren) in a way that indicates they may pose risk of Y/N harm to children, therefore potentially unsuitable to work with children.</p><p>Brief Description of the incident and resulting allegation / concerns raised with LADO: Any injury to victim, describe & provide date, time and place of incident if known? (please also provide detail of the incident / include a copy of incident report)</p><p>What actions have been taken to date?</p><p>4 Other Agencies / Professional Involved</p><p>Name Agency Tel number / Email</p><p>Return to: [email protected] or [email protected]</p><p>Please only email your completed form to the secure email address above if your own email address is secure, i.e. your email address is either GCSX, CJSM or your agency has a secure address such as Police, Health, Ofsted or NSCPCC.</p><p>5</p>