Self-Referral (please tick): / Yes: / If yes go to section 4 / No:
IMHA Referral Form
Section 1:Name of Referrer: / Date of Referral:
Role: / Team:
Contact Details:
Section 2:
Does the person being referred lack the capacity to instruct an advocate? / Yes / No
Has the person given their consent to this referral? / Yes / No
Section 3:
Date of Admission: / Start date of section: / Section type (e.g.S2 or CTO)
Date CTO commenced: / Renewal date for CTO:
Section 4:
Are there any deadlines or important meeting dates?
Section 5:
Are there any identified risks that we need to be aware of?
Section 6:
Client Name:
Date of Birth:
Gender: / Female: / Male:
Current Location (E.g. Hospital Ward):
Home Address:
Contact Number:
Section 7:
Are there any cultural or communication needs that we need to be aware of?
Section 8:
Reason for referral (e.g. new admission):
Please provide brief details of the issue(s) that require IMHA involvement:
-Please complete and return this form and fax it to:01706 508 599
-Response time to acknowledge receipt and allocation of advocate – 4 days.
-Please complete the Equality Monitoring form below.
-Tel: 0161 9332623
-Email:
Equality & Diversity Monitoring
Bury Advocacy Hub is committed to equality of opportunity. We need you to complete the following form so that we can assess whether we are reaching all sections of the community. If this is not completed at the time the referral is made, we will contact you for this information.
Gender: Male □ Female □ / Is your gender identity the same as the gender you were assigned at birth?□ Yes □ No
Sexual Orientation
□ Gay Man
□ Lesbian
□ Bisexual
□ Heterosexual
□ Other
………………………………….
□ Prefer not to say / Age or Date of birth
……………………………………………..
□ Prefer not to say
Do you consider yourself to have a disability?
The Disability Discrimination Act 1995 defines disability as a ‘physical or mental impairment which has a substantial and long term adverse effect on the ability to carry out normal day-to-day activities’.
Yes □ No □
Prefer not to say □
Disability
If you have answered “yes” to having a disability how would you describe it?
□ Physical Impairment
□ Visual Impairment
□ Learning Disability
□ Mental Health/Distress
□ Hearing Impairment/Deaf
□ Long term limiting illness
□ Other…………………………..
□ Prefer not to say / Religion/Faith
Do you have a religion or faith?
□ Yes □ No
If yes please select:
□ Buddhist □ Sikh
□ Christian □ Jewish
□ Hindu □ Muslim
□ Other religion or faith
……………………………………………..
□ Prefer not to say
Ethnicity
White:
□ British □ Irish
□ Other □
Asian:
□ Bangladeshi □ Chinese
□ Pakistani □ Indian
□ Other / Mixed
□ White & Black Caribbean
□ White & Black African
□ White & Asian□ Other
Black
□ African □ Caribbean
□ Other
…………………………………………..
□ Prefer not to say