Child Protection Concern Referral Form

Child Protection Concern Referral Form

(Not to be used by mandatory reporters to report sexual abuse that is occurring or has occurred after 1 January 2009).
Identifying data about persons providing information in good faith to the Department of Communities regarding concern for a child is protected under section 240 of the Children and Community Services Act 2004.

If you have concerns for the immediate safety or wellbeing of this/these child/ren, please contact the Department by telephone to ensure an immediate response on 1800 CPDUTY (1800 273 889).

For all child protection concerns outside of business hours, please call the Crisis Care Unit on 08 9223 1111

If you are a mandatory reporter, and have formed a belief that a child has or is being subject of sexual abuse, please submit a mandatory report.

You can call the Mandatory Reporting Service directly on 1800 708 704, or email MRS@communities.wa.gov.au for enquiries.

If you have concerns which are life threatening, please contact WA Police on 000.

You can save your progress at any time by clicking the ‘save’ button at the bottom of the screen. You will be sent an email with a link to continue the form at a later stage

If you are not the person who has first-hand information about concerns/disclosures, please provide details and contact information of the person who does have this information:
Name

First NameLast Name
Position title
Organisation
Contact phone
Contact email
example@example.com

Child 4 name*

First NameLast Name
Date of birth OR estimated age*
Date of birth

DayMonthYear
Date
Contact phone
Address*
Aboriginal and Torres Strait Islander background*
Culturally and linguistically diverse background*
If you need to enter details for more than four siblings, please include additional data at the end of this form.

Referrer's expectation

(Part 5 of 7)
Is/Are the children you are concerned about in the primary care of the person(s) believed to be responsible for the harm?
Are you aware if this/these person(s) is residing in the home?
Are there other children in the primary care of this/these person(s)?
If 'yes', please provide details

What is your relationship to the family?
How long have you known/been working with the family?
Have you addressed or discussed these concerns with this family? If so, please provide details (for example, conversations, date/s, meetings, etc.)
Is the family aware that this report is being made to the Department?
Do/Does the child/children of concern have any special needs?
If you answered 'yes' to the above, please provide details.

Considerations impacting the parent's/significant other's capacity to provide safety

(Part 6 of 7)
Are you concerned about parental substance/alcohol misues?
Do you believe the parent(s) have mental health issues?
Does the family have safe and stable accommodation?
Do the parent(s) have a physical or intellectual disability?
Please provide any further relevant details as necessary regarding the parent's/significant other's capacity to provide safety to the child/children.

Safety factors

(Part 7 of 7)
Are the child/children attending school/day care on a regular basis?
Are the family currently engaged with any support services
Are there people outside the immediate family who have regular contact with the child/children? (If known, please provide contact information).
Please provide any further relevant details as necessary regarding safety factors.
Please attach any additional data not included in this form that you wish to provide.

Cancelof
Thank you for completing this report. After you submit your responses, a copy will be forwarded to the email you provided in the Reporter Details section.
Please verify that you are human*
Should be Empty:

	Yes	No
Physical abuse
Sexual abuse
Family and domestic violence
Emotional abuse - other
Neglect

Reporter details