Page 1 of 5
For Internal Use OnlyReferral 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
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: 08444 432459
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.
IMCA Referral Form – July 2012
Registered Charity 1076630 Limited Company 3798884