IMCA Referral Form
Advocacy Focus provides an Independent Mental Capacity Advocate to represent and support people who meet
all the following criteria:
1. The person has no appropriate friends or family to consult
2. The person referred lacks capacity to make a decision concerning:
a. serious medical treatment or
b. long term care and health moves (more than 28 days in hospital /8 weeks in a care home), or
c. care reviews, or
d. The person referred is subject to an adult protection case, whether or not appropriate family, friends or
others are involved
Referral Information
1) Details of Person Requiring IMCA
Full Name:
Date of Birth:
Permanent Address including postcode:
Permanent Contact Tel:
Registered GP Surgery:
Current Location (if different to permanent):
Current Tel No (If different to permanent):
Ethnic Background:
White
Mixed White
Asian or Asian British
Black or Black British
Chinese or other ethnic group
British
Irish
Other White
White & Black Caribbean
White & Black African
White & Asian
Other Mixed White (specify)
Indian
Pakistani
Bangladeshi
Other Asian (specify)
Black Caribbean
Black African
Other Black (specify)
Chinese
Other ethnic category (specify)
How does the client communicate?
English
Other spoken language (please specify)
British Sign Language
Words / pictures / Makaton
Gestures / Facial expressions / vocalisations
No obvious means of communication
Other (please state)
IMCA Referral Form
Does the client have a disability?
Mental Health problems
Serious physical illness
Learning Disability
None
Other general special needs (please state):
Nature of client’s impairment (choose one category only)
Unconsciousness
Autism Spectrum Condition
Mental Health problems
Serious physical illness
Acquired brain damage
Dementia
Learning Disability
Cognitive impairment
Combination
Other (please state):
2) Referrers Contact Details:
Name:
Role/Team:
Address:
E-mail:
Tel:
Fax:
3) Decision Makers Contact Details: (if different to referrer)
Name:
Role/Team:
Address:
E-mail:
Tel:
Fax:
4) Specific Decision to be made (please tick)
Serious Medical Treatment
Move of accommodation
Safeguarding
Adults
Care Review
Please Provide Further Information:
5) Capacity Assessment (please tick).
I have reasonable belief that the
person lacks capacity at this time but
may regain capacity
I have reasonable belief that the
person lacks capacity for the
foreseeable future
IMCA Referral Form
6) Family/Friend Involvement
Is there nobody (other than paid workers) whom the decision-maker considers are willing and appropriate to be
consulted about the decision? If you have deemed someone ‘inappropriate to consult’, please provide
details of this decision
7) Significant dates
When does the decision need to be made by?
Please give details of any impending meetings or
deadlines
8) Further relevant information
Please provide details:
9) Consent from Referrer
Because of the Data Protection Act 1998, we need signed authorisation to say that people agree to the IMCA
Service holding personal information (including the information on this form).
The person being referred is deemed to lack capacity, therefore, the referrer must sign to say they are referring
and providing information in the person’s best interests, acknowledging that the person referred lacks capacity to
make this decision.
I would like IMCA to do this work. I am providing this information and asking for this referral in the client’s best
interests.
Referrer’s signature
Date
10) Consent from Decision Maker (if possible)
I am instructing the IMCA service to do this work. They can keep records of the information on this form, and
other information provided that is needed to complete this work. I am asking for this referral in the best interest’s
of the person concerned.
Decision Maker’s Signature
Date
Please note: Before a formal instruction is accepted, authorisation will be required from the decision
maker. If it is not possible for a signature from the decision maker to be obtained before submission of
this form, IMCA will contact the Decision Maker direct to seek authorisation.
Once completed please email to: [email protected]
IMCA Referral Form
For office use only:
Case number (blue file)
Client number
Previous IMCA