All Wales Partners Prevent Referral Form

All Wales Prevent Partners Referral Form

Counter Terrorism Wales Prevent Referral Form

This form is designed to help articulate a concern under Prevent - where you are worried a person is susceptible to radicalisation. Complete as much of the form as you are able; doing so will ensure that the person gets the help they need to keep them and others safe.

If you are a member of public sector staff, and would like to check your concern, you should contact your organisation’s Designated Safeguarding Lead (DSL) or equivalent. If you are a member of the public and are concerned about someone, you should call the Act Early Support Line on 0800 011 3764, in confidence to share your concerns with a specially trained officer or you can call the Anti-Terrorism Hotline on 0800 789 321. More information on what to do if you have a concern is available under ‘Get help for radicalisation concerns’ on GOV.UK.

If you are deaf, hard of hearing or have a speech impairment, a police non-emergency number is available as a text phone service on 18001 101. Remember, in an emergency dial 999.

Once you have completed this form it is essential that you submit it to the police directly, or your DSL or equivalent will do this on your behalf. Where possible you will receive a response on your referral, but this is not always possible due to data-protection considerations and other sensitivities.

Where possible, do not leave any gaps, as the police may have to contact you to gather more information which will delay the process. If you cannot answer a question, explain why in the text box provided.

1. Details of Person Being Referred

Details of person being referred

Complete where information is known and applicable.

This information will not be used to assess whether a referral should be adopted. Any personal data provided may support Equality Act obligations. Please only provide personal data if this information is already known from an official source or was provided by the person in question.

Surname *

First name(s) *

DOB / Age *

Immigration or Asylum Status

Religion

Phone Number

Gender

Nationality

First Language

Email Address

Current Address *

Social media identifiers *

Parent or guardian contact details

Any other details that may be relevant to the concern

2. Discuss your concerns relevant to prevent

How/why did the person first come to your notice? *

What is the person’s ideology or belief of concern if known? For example, extreme right-wing terrorism (ERWT), Islamist terrorism, left wing, anarchist and single-issue terrorism (LASIT) *

What specific concerns do you have? Such as, have they had contact with extremist groups or people that worry you, discussed travel plans to a conflict zone, threatened anyone with violence, shown interest in hate crimes, extremists, or terrorism, or used their mobile phone, internet or social media in a way that worries you. *

Describe any other concerns you may have.

5. Your details

Surname *

First name(s) *

Organisation *

Phone number *

Email Address *

Relationship to the person *

Role or job title

Address of Organisation

6. Details of the person who first identified the concern (if different from above)

Surname

First name(s)

Organisation

Phone Number

Email address

Role or job title

Address of organisation

7. Details of the person you have shared the concern with

Provide the details of the person you have shared the concern with if known for example, your Designated Safeguarding Lead or equivalent, or Prevent police

Surname

First name(s)

Organisation

Relationship to the person

Email address

Role or job title

Phone number

8. Relevant dates

Date concern was first identified

Date of referral to Prevent

9. Safeguarding considerations

10. Employment/education details of the person of concern

Current occupation and employer:

Previous occupation(s) and employer(s):

Current school/college/university:

Previous school/college/university:

Not currently in education or employed:

11. Additional Information

If there is anything you have not been able to add to the form, but feel is relevant, please provide details or a contact number below

Details

Thank you for taking the time to make this referral.

Information you provide is valuable and will always be assessed. If there is no Prevent concern but other safeguarding issues are present, this information will be sent out to the relevant team or agency to provide the correct support for the person concerned.

The Home Office and Counter-Terrorism Policing regularly conduct research in order to continuously improve the delivery or Prevent, and may contact you to invite you to participate in such research.

Tick this box if you do not with to be contacted for research-related purposes