Multi-Agency Mental Capacity Assessment FormName of Service User:
Date and time of capacity assessment:
Name and signature of person carrying out capacity assessment:
Professional Role/ Job role of person carrying out this assessment:
2.Impairment or disturbance in the functioning of the Mind or BrainIs there an impairment or disturbance / Yes / No
If so, describe the impairment or disturbance. If not then do not continue with capacity assessment
3. The Decision to be MadeWhat decisions/ actions does person needs to make/ take?
Please detail why capacity is in doubt.
4.Functional Test of Capacity (1 or more negative elements (A to D) indicates a lack of capacity in relation to this decision)A) Understanding the Information Relevant to the Decision
(Does the person have a general understanding of the decision they need to make and why they need to make it? (Including the reasonably foreseeable consequences of deciding one way or another, or of failing to make a decision?)
B) Retain the Information Long Enough to Make a Decision
(The fact that a person is able to retain the information for a short period only does not prevent them from being regarded as able to make the decision)
C) Use or Weigh up the Information to Make a Decision
(Degree of awareness and insight, evidence of reasoning processes)
D) Communicating the Decision
(To produce a response, not necessarily verbal that indicates choice, in a way recognised by the assessor).
If the person is deemed to lack capacity on any one of the sections A-D this means the
person lacks capacity at this time to make the decision outlined above.
(If this is the case then a Best Interests decision must be now be made)Please detail any attempts to optimise understanding and maximise capacity here:
i.e. providing relevant information to enable informed choices to be made, communicating in an appropriate way, making the person feel at ease; quiet environment, time of day and providing support etc.)
5.IMCAIf the person has no family or unpaid friends an IMCA is required for any subsequent Best Interests decision. Is an IMCA required for this reason? (if yes, contact an IMCA before taking further action) / Yes / No
If a decision as to Best Interests needs to be made as part of a Safeguarding procedure and it is inappropriate to consult family or unpaid friends an IMCA is required for this decision. Is an IMCA required for this reason? (if yes, contact an IMCA before taking further action) / Yes / No
Date of referral to IMCA
Has referral been accepted by IMCA service? / Yes / No
6. Outcome of the Capacity Assessment (please select one):
The person does not lack capacity to make the above decision
I have completed my assessment. I have determined that the person named in this form has the mental capacity to make their own decision relating to the specific decision named in section two of this form.
The person’s decision will now be accepted as valid in accordance with the Mental Capacity Act 2005.
The person lacks capacity to make the above decision
I have completed my assessment. I confirm that I have assessed the person named in this form and determined that they lack capacity relating to the specific decision named in section two of this form.
Can this decision wait? Is the person likely to regain capacity to make the decision in a reasonable timescale without being detrimental to the person’s wellbeing?
In accordance with the requirements of the Mental Capacity Act 2005, I will now co-ordinate the Best Interests Process.
If you have any queries regarding this form then please speak to the Safeguarding Lead within your own organisation.