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For Internal Use Only
Referral Received Date / / / /
Date first contacted / / / /
Date of appointment / / / /
Time of appointment / :
Allocated Advocate Name
NHS Number / Social Care Number
About the Person
A / Name of Person:
B / Current Place of Resident (at date of referral):
Telephone Number:
C / Has the Equal Opportunities Form been completed? / Yes No / Date of Birth:
D / What is the Best Interest Decision?
Serious Medical Treatment / Long Term Accommodation / Adult Protection / Care Review
Please describe the decision:
For Long Term Accommodation, what is the projected discharge date?
E / Date decision need to be made by: / Meeting dates (please specify)
F / Capacity Assessment
Name and position of the profession who had decided the referred person lacks mental capacity to make a decision on the referral issue:
Has a 2 stage functional assessment of capacity been carried out? / Yes No
G / Family and Friends
Does the referred person have a family? / Yes No / And/or friends? / Yes No
Are the person’s family appropriate to be involved in the best interest decision? / Yes No
If no, what is the reason the family are not involved?
Risk and Support Needs
H / Support Needs - Please detail any support needs the advocate will need to provide advocacy support e.g. 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 process:
Key People
J / Professional making the best interest decision: / Referrer (if different from decision maker)
Print Name
Position
Organisation
Tel No
Mobile No
Fax No
Email
Pager
K / Involved professionals (not listed above) and contact details
L / Is the referred person aware of the advocacy referral? / Yes No
M / Signature (Referrer) / Date:
N / Signature (Decision Maker)
O / PLEASE RETURN THE COMPLETED FORM TO: / VoiceAbility, Mount Pleasant House, Huntingdon Road, Cambridge, CB3 0RN
IMCA FAX: 0208 330 6622
Email:
Do you consider the person you are referring as:
Male / Transgender / Female / Prefer not to say
How would you describe their ethnic origin or background?
White British / English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background, write in
Mixed and Multiple Ethnic Groups / White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / multiple ethnic background, write in
Asian / Asian British / Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background, write in
Black / African/ Carribean / Black British / African
Caribbean
Any other Black / African / Caribbean background, write in
Other Ethnic Group / Arab
Any other ethnic group, write in
How would you describe their sexuality?
Heterosexual / Straight / Homosexual / Gay/Lesbian / Bi-sexual / Prefer not to say
How would you describe their religious beliefs?
No Religion / Jewish
Christian / Muslim
Buddhist / Sikh
Hindu / Any other religion, please specify
Prefer not to say
Do you consider them to have the following?
A Learning Disability / Mental Ill Health
A Physical Disability / A Sensory Impairment
Dementia / Autism
An Acquired Brain Injury / Dementia
Physical Ill Health / Other (Please specify)
Prefer not to say
**Referral Receipt**
VoiceAbility will confirm receipt of all IMCA referrals within 24 hours. If you have not received this confirmation, please contact VoiceAbility on the above contact details.

Please forward this referral form, along with a copy of the MCA-2 to

or 0208 330 6622

If you have any queries please call us on 0845 017 5198

IMCA Referral Form – March 14

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