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IMCA Services Referral Form
Appendix1
IMCA Ref No.
IMCA
The Advocacy Trust Gloucestershire (ATGlos) IMCA service provides an Independent Mental Capacity Advocate to represent and
support people who meet all the following criteria;
1. 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. residential care reviews,
and they have no appropriate family or friends to represent them
2. The person referred lacks capacity and is subject to an adult protection case, whether or not appropriate family, friends or others are
involved
Referrals can be made by telephoning 0845 0511203 between 9am and 5pm Monday to Friday.
Name of client
/name usually known by
Date
Date of birth
Gender
Address
Telephone no.
Postcode
GCCSSCN02 May 2011
White
British
White
Irish
Black
Caribbean
White/black White/Asian
Caribbean
Other white Black
Other black White/black Other mixed
background African background African
background
Bangladeshi
Indian
Chinese
Pakistani
Other Asian
background
Other Ethnic group
Primary communication
English
Another spoken language?
Gestures/vocalisations/facial expressions
Pictures/symbols/Signs
BSL
Other
No obvious communication
What is the understanding
of the person’s capacity to
make this decision?
Lacks capacity to make this For the foreseeable future
decision
At this time
On what basis was the
decision about the persons
capacity made?
Decision-maker’s judgement
Other
Client group/ reason for
lacking capacity
Learning disability
Autistic Spectrum Disorder
Mental Health
Serious physical illness
Dementia
Acquired brain injury
Unconscious
Other
Accommodation
Serious Medical
Treatment
What is the decision to be
made about?
When does the decision
need to be made by?
When are any deadlines or
important meeting dates?
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Assessment by another
professional
Care Review
Adult Protection
DoLs
Where is the person currently staying?
Own home
Care/nursing
home
General
hospital
Psychiatric
hospital
Uncertain
Other
What is the decision-maker’s
recommended course of action?
Are there any family/friends?
Yes
No
Uncertain
If there are family, friends etc., why is an
IMCA needed?
Names and contact details of GP and
GP
Care Manager (if relevant), and anyone
else who may be able to indicate the
wishes of the person who lacks capacity
e.g. Manager of home, speech therapist,
care staff, nurses, or any other
significant person.
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CARE MANAGER/SOCIAL WORKER
KEY WORKER
Any other relevant
information.
Name and position
of referrer
Telephone
Address
Email
Mobile
Is the referrer the
YES
decision maker?
If not, give the name Name and position of
and contact details
decision maker
of the decision
maker
NO
Address
Telephone
Email
The Advocacy Trust Gloucestershire (ATGlos), Suite 4, Westend Courtyard, Westend, Stonehouse, Gloucestershire. GL10 3SL
Telephone: 0845 0511203 Fax: 01453 822264 Email: [email protected]
GCCSSCN02 May 2011