For Children &Young People Only

Page 1 of 6

About the person

Name of the person:
Please describe the specific reasons why you are requesting advocacy support for this person:Please give as much information as possible to help us identify which type of advocacy is required. If you know you are referring for an IMCA, IMHA or Care Act please also complete the relevant additional questions at the end of this form.
Has the person being referred requested an advocate? / Yes No / Has the person agreed to this referral for advocacy? / Yes No
Current place of residence (at date of referral):
Tel No: / Mobile Tel No:
Date of Birth:
Email Address:
Does this person have capacity around the referring issue? / Yes No Fluctuating
Is the referred person an informal carer? / Yes No
Does the person have the following?
Learning Disability Mental Health Difficulties Dementia
Acquired Brain Injury
Sensory Impairment Physical Impairment ASD
Neurological Condition
Physical Ill Health Substance Misuse Eating Disorder Other
Support needs - Please detail any support needs the advocate needs to be aware of to provide advocacy e.g. Any long term condition, Language or preferred communication methods:
Risks - Please detail any information needed to ensure the safety of the advocate and the referred person during the advocacy:

About the referrer

Referred by: / Self / Professional / Other
If you are making a referral on behalf of another person please provide your details: / Print Name
Position/relationship to person
Organisation
Team/Department
Tel No
Mobile No
Fax No
Email

For Children &Young People Only

If consent if required, who is this person’s parent or guardian? / Yes No
Address and contact details for Parents or Guardians (where appropriate):
Address of School, details of class and contact details for any relevant teacher (where appropriate):

Signature

Signature (Referrer) / Date
Time
Date Sectioned: / Section:
Date Admitted:

(Continued overleaf, please turn over)

What is the Best Interest Decision to be made?
Decision Maker Name and Contact Details?
Is there a date a decision needs to be made by: / Yes Date: No
Does the referred person have any family or friends appropriate to consult? / Yes No
Has a 2 stage functional assessment of capacity been carried out? / Yes No
*Please send the capacity assessment once complete*
Is the referral for: / Please tick / Referral Category / Please tick
An adult with care & support needs / Assessment
A carer with support needs / Planning
A young person with care & support needs / Review
A young carer with support needs / Safeguarding
Advice and Information
Does the person have an appropriate individual to support them?
If yes, please outline why an advocate is still required. / Yes / No
Gender?
Male / Transgender / Female / Prefer not to say
Ethnic origin or background?
White British / English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background, please write in
Mixed and Multiple Ethnic Groups / White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple Ethnic background, please write in
Asian / Asian British / Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background, please write in
Black / African/ Caribbean / Black British / African
Caribbean
Any other Black / African / Caribbean background, please write in
Other Ethnic Group / Arab
Any other ethnic group
Prefer not to say
Sexuality?
Heterosexual / Straight / Homosexual / Gay/Lesbian / Bi-sexual / Prefer not to say
Religious beliefs?
No Religion / Jewish
Christian / Muslim
Buddhist / Sikh
Hindu / Any other religion, please specify
Prefer not to say

Total Voice Suffolk – Referral Form – For Professionals – last updated Dec 17