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Sutton IMCA Service

REFERRAL FORM

To make a referral please complete the form and email it to

BEFORE COMPLETING FORM:

  • Identify thedecision maker e.g. the person responsible for making the final decision. Usually it is the Consultant/GP for serious medical treatment or the Care Manager for change of accommodation. The decision maker must give permission for this referral to be put forward.
  • Ensure that the client’s capacity for this particular decision has been assessed – it should be time and decision specific. Specify who assessed capacity, when, and where this is recorded.
  • Establish that the client is unbefriended – e.g. no family or friends who are willing and able to be involved in the best interest decision. If you decide family/friends are “not appropriate” – please give the reason.

COMPLETING THE FORM:

  • Complete one referral form PER DECISION.
  • Type your answers onto the shaded areas which expand as you type.
  • In each section choose ONE ANSWER ONLY.
  • When required to specify or give details – delete “specify” and type in your answer
  • To change a pre-answered “yes or no” question - click on the answer and a drop down box will appear.
  • If a client has more than one impairment please choose the “combination” box . More detail can be entered under the “Any other relevant information”.
  • Do not complete the “For office use only” sections.

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SUTTON IMCA SERVICE REFERRAL FORM

Referrer’s Name:
Relationship to client:
Job title:
Organisation & address:
Tel:
Mobile:
Email:
Is the referrer the decision maker? YesNo
If no, is the decision maker aware of this referral? Yes / Client Name:
Date of birth:
Home address:
Tel:
Is this a first referral? YesNo
In the case of a referral relating to Adult Protection proceedings state whether the client referred is:
The alleged victim
The alleged perpetrator
Date of referral:
Type of referral (see below):
Serious Medical Treatment
Change of Residence
Adult Protection proceedings
Care Review
Date of proposed action: / Decision Maker Name:
Job Title:
Organisation & address:
Tel:
Ext/bleep:
Mobile:
Email:
Please confirm that the following has been carried out:
Test of capacity undertaken & decision made
(Who carried out test? When? Where are notes held?):
Client is un-befriended
If family or friends are available please state why a referral has been made:
Not willing
Not appropriate:
Nature of client’s impairment:
Unconsciousness
Autism Spectrum Condition
Mental Health problems
Serious physical illness
Acquired brain damage
Dementia
Learning Disability
Cognitive impairment
Combination
Other: Please specify / Does the client have disability?
Mental Health problems
Serious physical illness
Learning Disability
No/not known
Other general special needs:
Primary means of communication:
English
Other spoken language
British sign language
Words/pictures/Makaton
Gestures/facial expressions/vocalisations
No obvious means of communication
Other:
Religion:
Buddhist
Catholic
Christian
Hindu
Jewish
Muslim
Sikh
None
Not known
Declined to give
Other:
Ethnic background of client:
White
British
Irish
Other White
Mixed White
White & Black Caribbean
White & Black African
White & Asian
Other Mixed White
Asian or Asian British
Indian
Pakistani
Bangladeshi
Other Asian: Please specify / Black or Black British
Black Caribbean
Black African
Other Black: Please specify
Chinese or other ethnic group
Chinese
Other ethnic category: Please specify
Other
Not established
Serious MEDICAL treatment – what is the decision to be made?
Cancer treatment
Hip/leg operation
DNAR (do not actively resuscitate)
Medical investigations
Serious dental work
Treatment that may lead to loss of hearing or sight / ECT
Major surgery (e.g. open heart or brain/neuro-surgery)
Major amputations (arm or leg)
ANH (artificial nutrition & hydration)
Termination of pregnancy
Other: Please specify
Change in ACCOMMODATION
From:
Own home
Care/nursing home
Hospital
Supported living
Prison
Other Please specify / To:
Own home
Care/nursing home
Hospital
Supported living
Other Please specify
To be decided
Care review:
Details: / Adult protection:
Details:
Where was the client at the time of referral?
Own home
Care/nursing home Please enter name
Hospital Please enter name
Supported living Please enter name
Uncertain
Prison Please enter name
Other Please enter
Does the client have an attorney, receiver or guardian? YesNo Please give name & telephone number and clarify the issue that they are dealing with:
Has the client issued an advance decision? YesNo If yes where is this held? Please give name and telephone number (usually medical or social care records):
Are you aware of any other forms of record of the client’s wishes? YesNo If yes, in what form are they held, who holds them and where are they held. Name and telephone number needed:
Does the IMCA need to be aware of any risks, hazards or infections when dealing with this case? YesNo Please give details
Who should the IMCA first contact?
The referrer
The decision maker / Any other relevant information:
FOR OFFICE USE ONLY
Does this referral meet the criteria for an IMCA?
Yes
No
If no please say why and note any action that has been taken:
Referral allocated by:
Referral allocated to: / FOR OFFICE USE ONLY
Client ID number:
Approx time spent taking referral:

March 2011