Referral form
Independent Advocacy under the Care Act
Please complete and return to: VoiceAbility, Total Voice Wakefield, The Gaslight,
Lower Warrengate, Wakefield, WF1 1SA
Tel: 01924 688032 / Fax: 01924 918474 / Email: [email protected]
About the Referrer
About the referrer
Date:
Referral Team:
Name of person making the referral:
Organisation the referrer works for:
Job Title:
Telephone number:
Email address:
About the Person
Name of person requiring support:
Telephone number:
Date of birth:
Address:
E-mail address:
Preferred contact method:
Preferred language:
Any other communication needs:
Consent
Where appropriate, have you discussed the referral to advocacy with the
person? (If no, we will contact you prior to making contact with the person.)
Has the person agreed to this referral being submitted?
Signature of referrer:
Signature of client (if possible):
Advocacy Referral Form – January 2015
Registered Charity 1076630 Limited Company 3798884
Yes
No
Yes
No
Referral Details
Is the referral for:
Please
tick
Please
tick
Referral Category
An adult with care & support needs
Assessment
A carer with support needs
Planning
A young person with care & support needs,
going through transition
Review
A young carer with support needs
Safeguarding
Advice and Information
Background and Additional Information
Care and Support needs: Please detail any support needs the advocate needs to be aware of to provide
advocacy e.g. any long term condition or impairment.
Nature of Substantial Difficulty (please tick each relevant box)
Understanding relevant information
Using or weighing up information
Retaining information
Communicating their views wishes and
feelings
Where possible, please elaborate on what difficulties the person has in being fully involved in the process.
Do you suspect the person lacks capacity on any of the referral categories
above?
What additional support, if any, is available to the person?
Advocacy Referral Form – January 2015
Registered Charity 1076630 Limited Company 3798884
Yes
No
Risks - please detail any information needed to ensure the safety of the advocate and the
referred person during the advocacy process
Any other relevant information / specific needs:
Advocacy Referral Form – January 2015
Registered Charity 1076630 Limited Company 3798884
Equal Opportunities
Completing on Behalf of Referred Person
If the referred person is unable to indicate the information below due to limited
communication or lacking capacity around these questions, and you as the referrer
have completed on their behalf, please tick the box to the right.
Name:
Date:
Do you consider yourself:
Male
Transgender
Female
Prefer not to say
How would you describe your ethnic origin or background?
White British
Mixed and
Multiple Ethnic
Groups
Asian / Asian
British
Black / African/
Carribean / Black
British
Other Ethnic
Group
English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background, please write in
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple Ethnic background, please write in
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background, please write in
African
Caribbean
Any other Black / African / Caribbean background, please write in
Arab
Any other ethnic group, write in
Prefer not to say
Advocacy Referral Form – January 2015
Registered Charity 1076630 Limited Company 3798884
How would you describe your sexuality?
Heterosexual / Straight
Homosexual /
Gay/Lesbian
Bi-sexual
Prefer not to
say
How would you describe your religious beliefs?
No Religion
Jewish
Christian
Muslim
Buddhist
Sikh
Hindu
Any other religion, please specify
Prefer not to say
Do you consider yourself to have? (Tick all that apply)
A Learning Disability
Mental Ill Health
A Physical Disability
A Sensory Impairment
Dementia
Autism
An Acquired Brain Injury
Physical Ill Health
Prefer not to say
Other (Please specify)
Advocacy Referral Form – January 2015
Registered Charity 1076630 Limited Company 3798884