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How to Complete the IMCA Referral
Form
A
Please enter the referred person’s full name
B
Current Place of Residence; this is where the referred person resides at the time of
referral.
C
Insert telephone number and date of birth
D
Tick which type of Best Interest Decision and outline the details of the decision; the
decision must be one of these options to quality for an IMCA. You need to refer to
your Local Authority guidelines for reviews/FORMAL Adult protection proceeding
referrals.
For Long Term Accommodation, please indicate a date for the projected discharge.
E
The decision should be made after consultation with the IMCA. Please indicate a date
the decision needs to be made by. This is important to help us prioritise how quickly
we need to provide an IMCA.
Please list dates such as operations, Best Interest meetings. This is important to help
us prioritise how quickly we need to provide an IMCA. It also helps us plan the IMCA’s
time more effectively.
Registered Charity 1076630
Limited Company 3798884
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F
Capacity Assessment; Please insert the name and position of the professional
responsible for the capacity assessment and tick whether a 2 stage functional
assessment has been carried out.
It is the decision maker’s responsibility to follow the capacity test in the Mental
Capacity Act. The decision maker must assess the person’s capacity to make the
decision to which they are referring. A capacity assessment by a doctor is not needed
for a referral to IMCA.
G
Family and Friends: please indicate whether the referred person has family, whether
they are “appropriate” to consult with and any reasons why they may not be
appropriate.
An IMCA can only be provided in serious medical treatment/long term moves/care
reviews if there are no “appropriate” friends and family to consult with. It is the
decision-maker’s decision as to whether the family or friends are appropriate to
consult with. Please read the VoiceAbility “Appropriate to Consult” guidance if
you are unsure.
You need to have justifiable reasons for deciding the person’s family or friends are not
appropriate to consult with. In adult protection circumstances, you need to follow your
Local Authority guidelines.
In most circumstances, friends and family should be informed of IMCA Involvement.
Our “FAQs for Family and Friends’ guidance is available, and should be
forwarded to those involved.
H
Please indicate any support needs the IMCA may need to be aware of to undertake
the advocacy. Please indicate whether an interpreter / signer is needed.
I
If there are any safety issues regarding health or behaviour which may put the
advocate or the referred person at risk, please list them here. Include risks posed by
other family members if appropriate.
Registered Charity 1076630
Limited Company 3798884
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J
The referrer details should be the decision-maker. The decision-maker is the person
employed by the Local Authority or NHS body to action a decision. This is usually a
care manager or a doctor. In some Local Authorities, there are “gate keepers”, usually
team leaders who you may need to approach to authorise your referral. Please check
this with your manager.
We may accept an alert from some-one other than the decision-maker where the
referrer has been unsuccessful in persuading the decision-maker to refer and it seems
likely that the person meets the criteria for an IMCA. Also, if the decision maker is not
readily available to complete the referral form, we can take a referral form from
another professional in the same team. However, in both situations, decision maker
details need to be given and we will then contact them to confirm referral
authorisation. If you are the referrer but not the decision maker, please insert your
details in this section.
Please include all your contact details as this helps speed up communication. Please
include the Local Authority or NHS body that employs you.
K
Please list contact details of people that the IMCA will need to speak to. This should
include where relevant G.P., consultant, care manager, key worker, care workers, day
centre, employer, friends, family, colleagues. Providing this information enables the
IMCA to respond faster.
L
Please indicate whether the referred person has been made aware of the referral
M
If you are the referrer but not the decision maker, please ensure you sign and date this
section.
N
If you are the decision maker, please ensure you sign and date this section
Registered Charity 1076630
Limited Company 3798884