IMHA Referral Form

For use by external agencies

This form can be printed out, and faxed or sent by post to the appropriate Asist office or filled in electronically and emailed (see contact details at end of form).

What section of the M.H. Act is the service user under?
Date of referral

Service User’s Contact Details:

Service User’s Name
Date of Birth
Service User’s Current Address
Telephone no.
Service User’s Home Address
(if different)
Telephone no.
Does the service user know that they are being referred to Asist?
Are you aware if the service user has had an advocate from Asist before?

Referrer’s contact details

Name
Relationship to service user
Address
Telephone no.
Date referral
sent to Asist

Other information

Is there any history of violence or any significant risks attached to working with this person?
Is there any essential information the advocate needs prior to meeting the person?
What are the tasks?
Why does the service user want an advocate?
Is there a specific deadline – tribunal or similar, that we should know about?
Are there any specific instruction we need regarding contacting you or the service user?

Preferred Communication Method of the Service User:

Spoken Language / Gestures / Facial Expressions / Vocalisations / Words / Pictures / Makaton
British Sign Language / Communication method unknown / Other (specify below)

Ethnic background

White: / Asian or
Asian British: / Mixed: / Black or
Black British: / Chinese or not established
British
Irish
other / Pakistani
Bangladeshi
Indian / White & Black Caribbean
White & Black African
White & Asian / Black Caribbean
Black African / Chinese
Ethnicity not established
Other (specify)

Asist Offices

Burton on Trent
ASIST - IMHA
Waterside Court
Studio 2 –
3rd Avenue
Centrum 100
Burton on Trent
DE14 2WQ
Tel: 01283 564772
Fax: 01283 64772 / Stoke-on-Trent
ASIST – IMHA
Winton House
Stoke Road
Stoke-on-Trent
ST4 2RW
Tel: 01782 845584
Fax: 01782 746647 / Stafford
ASIST – IMHA
St Alban’s House
St Alban’s Road
Stafford
ST16 3DP
Tel: 01785 46709
Fax: 01782 246731 / Harplands Hospital
ASIST – IMHA
Harplands Hospital
Hilton Road
Stoke-on-Trent
ST4 6TH
Tel: 01782 441630
Email:

IMHA advocates are supplied by Asist Advocacy Services.