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About the PersonA / Name of the Person:
B / Please describe the specific reasons why you are requesting advocacy support:
C / If the person is sectioned under the Mental Health Act please complete section below;
Date Sectioned: / Date/time of Admission:
Section: / Which Funding Authority:
Informed of MHA rights? / Yes No / Community Treatment Order: / Yes No
D / Current Place of Residence (at date of referral):
E / Tel No: / Date of Birth:
Email Address
F / Statutory IMHA eligibility (Coventry and Warwickshire)
To qualify the client must fall under at least one of the criteria below
Detained under the Mental Health Act (but not under detained under Sections 4, 5(2), 5(4), 135 or 136
Conditionally discharged restricted patient;
Subject to Guardianship under the Mental Health Act
On Supervised Community Treatment (SCT);
Being considered for treatment to which Section 57 applies
Under 18 and being considered for electro-convulsive therapy or any other treatment to which Section 58A applies.
n.b. this service covers patients who do not usually reside in Coventry or Warwickshire, but are receiving treatment in Coventry or Warwickshire / Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
In-Patient IMHA eligibility (Warwickshire only)
To qualify the client must fall under all criteria below
Has a home address in Warwickshire or is registered with a Warwickshire GP
Is currently residing in a Mental Health unit but not detained under the act / Yes No
Yes No
Community IMHA eligibility (Warwickshire only)
To qualify the client must be registered with a Warwickshire GP or usually reside in Warwickshire and fall under at least one criteria below;
Section 117 clients
Section 41 clients
Others, as referred by an Approved Mental Health Professional (AMHP), GP or other relevant professional on the basis of their vulnerability and need for time-limited support which aids their independence. / Yes No
Yes No
Yes No
G / Is the Referred person an informal carer? / Yes No
Risk and Support Needs
H / Support Needs - Please detail any support needs the advocate needs to be aware of to provide advocacy e.g. Any long term condition, Impairment, Language or preferred communication methods:
I / Risks - Please detail any information needed to ensure the safety of the advocate and the referred person during the advocacy:
Key People
J / Referred by: Other / Self / Professional / Other
If you are making a referral on behalf of another person please provide your details: / Print Name
Position or Relationship to person
Organisation
Tel No
Mobile No
Fax No
Pager
K / If you are making a referral on behalf of another person, is the person aware of the referral? / Yes No
If no, please outline reasons for this
L / Involved professionals & contact details
(if relevant):
For Children &Young People Only
M / If consent if required, who is this person’s parent or guardian?
Address and Contact details for Parents or Guardians (where appropriate):
N / Signature (Referrer) / Date
Time
Please email this form to or fax it to 0330 0883804
If you have any questions or queries please call 0300 222 5947
Advocacy Referral Form – March 2014
Registered Charity 1076630 Limited Company 3798884