CARE ACTREFERRAL FORM 2016

Please complete all the fields on the form

Date of Referral / Client ID Number
(Cambridge House use only)
Client Details
Client Name / Client DOB
Home Address
Address at point of referral (if different from above). If hospital please include ward number.
Postcode / Borough
Telephone / Email
Type of Referral (please tick only one box per referral) / Referrer Details
Needs Assessment / Name of Referrer
Preparation of Care And Support Plan / Job Title
Safeguarding / Team
Review of Care and Support Plan / Department
Complaint/Appeal / Telephone
Details of Referral / Email
Borough
(Please give clear details about the issues with which advocacy support is required. Use additional sheets if necessary)
ONLY COMPLETE BELOW SECTION IF CLIENT HAS CAPACITY
Consent
Is the client aware of, and has consented to, the Referral? / Yes / No
ONLY COMPLETE BELOW SECTION IF CLIENT LACKS CAPACITY
Details of person who believes the referred client lacks capacity to make the proposed decision
Name / Job Title
Team / Department
Borough / Address
Telephone / Email
Has a Capacity Assessment (as required by S.2 and S.3 of MCA 2005) been carried out? / Yes / No
If yes, where can it be located?
Other People Involved
Contact details of other relevant people (professionals, family or friends)
Name / Relationship to client / Telephone / Email
Client Need (please enter x in relevant boxes) / Mental Health Act Status (please enter x in relevant box)
Mental Health / Is the client subject to the Mental Health Act? / Yes / No
Learning Disability
Dementia / If yes, please indicate which section and why it is required
Acquired Brian Injury
Serious physical Illness
Cognitive Impairment
Other …
Ethnic Background / Primary Means of Communication (please enter x in relevant box)
(please enter x in relevant box) / M / F
White British / English
White Irish / Other spoken language Please specify…
White Other
Mixed White & Black Caribbean / British Sign Language
Mixed White & Black African / Words
Mixed White & Asian / Pictures
Other mixed / Makaton
Asian or Asian British Indian / Gestures
Asian or Asian British Pakistani / Facial Expressions
Asian or Asian British Bangladeshi / Vocalisations
Chinese / No obvious means of Communication
Other Asian / Comments
Black or Black British Caribbean
Black or Black British African
Other
Withheld
Risk Assessment
Are there any risk issues or incidents the Advocacy service should be aware of? / Yes / No
If Yes, please give details:
Name and details of person completing this referral form
Name / Email
Telephone No / Relation to client
Job Title / Date:
Please Return This Referral Form to

Or post it to us
IMCA, Cambridge House, 1 Addington Square, London SE5 0HF