MCADRF171207
Mental Capacity Assessment Form
Name:
Name of Assessor:
Location:
Role of Assessor:
D.O.B:
Contact No:
I am completing this assessment form on (date)…………………….. because the patient named above appears
to lack capacity at this time
(Assessment context -Remember assessment of Mental Capacity must be decision and time specific)
What is the nature of the decision? (Details)
Determination of capacity (This is specific, not general determination ) See Decision Making flow chart the
Mental Capacity Interim policy and the Mental Capacity Act Code of Practice
Is there an impairment of, or disturbance in, the
Permanent 
Temporary 
None 
functioning of the person’s mind or brain?
impairment
impairment
Details:
Yes 
Can the decision be delayed because the person
is likely to regain capacity in the near future?
Details:
Not likely to 
regain capacity
Not appropriate
to delay

1. Person has ability to understand information related to the decision to be made?
Details:
Yes 
No 
2. Person has ability to retain information related to the decision to be made?
Details:
Yes 
No 
3. Person has ability to use or assess the information whilst considering the decision?
Details:
Yes 
No 
4. Person has ability to communicate their decision by any means?
Details: state what steps have been taken to achieve communication.
Yes 
No 
If you have ticked any of the above questions 1 to 4 as NO then this person lacks capacity at this time
What steps have been taken to enable or assist the person to make or be involved in this decision?
e.g. visual aids
Advance decisions (Note any documentation referenced)
Is there any advance decision relevant to
this decision?
No 
Yes 
If yes
verbal 
(Detail below)
Written 
(Detail below)
PTO
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Sept 2012
Details:
Best Interests: ( What other considerations have been taken into account when assessing this person’s best
interests )
Yes 
(see below)
Section A: Does the person have a Next of Kin/
Person who can inform decision making?
No 
(see Section B)
If ‘Yes’ state :
Name of Persons who can help make decision ………………………………………………………….
Relationship………………………………………………………………………………………………..
Do they have Lasting Power of Attorney or enduring Power of Attorney Yes 
No 
Date of your discussion with them on your findings…………………………………………………….
Did you agree the appropriate way forward for this patient?
Yes 
No 
If ‘No’ state what help you are going to find to resolve this disagreement:
Details:
NB referral to IMCA may be appropriate if there are Safeguarding Adult issues
Section B: If there is no (unpaid)person who can help inform the decision making process, you must refer to
IMCA.
Name of person completing form: …………………………………………………………………………………..
Role ……………………………………
Date form completed…………………………………………….
Name and role of person making referral (Decision maker)……………………………………………………………
(if different from the person completing the form)
Signature of Capacity Assessor …………………………………………… Date of referral: …………………………
Best Interest Decision (The Decision maker must record details of final decision made including reference to
the Best Interest checklist and Best Interest Meeting notes) :
Will the person regain capacity?
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Sept 2012
Can we delay the decision?
Should we delay making the decision?
Have we all the relevant information that needs to be considered?
How did we involve the person in this decision?
What are their wishes, feelings, values and beliefs?
Do we have any information about the views they have expressed in the past that would help to
understand what their wishes and feelings might be?
What are the views of their family members, parents, carers and other relevant people who support or
are interested in their welfare?
Do we need to involve an independent Mental Capacity Advocate (IMCA)?
What is the decision?
Signature of Decision Maker……………………………………………………
Date………………………
File original in person’s records, if referring to IMCA attach copy of form to the IMCA Referral Form see
www.livingoptions.org/imca for referral form.
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Sept 2012