Page 1 of 5
For Internal Use Only
Referral Received Date
Date first contacted
Date of appointment
Time of appointment
Allocated Advocate Name
/
/
/
:
/
/
/
NHS
Number /
Social Care
Number
IMCA Referral Form
About the Person
A
Name of Person:
B
Current Place of Resident (at date of
referral):
Telephone Number:
C
Has the Equal Opportunities Form
been completed?
D
Yes
No
Date of Birth:
What is the Best Interest Decision?
Serious Medical
Treatment
Long Term
Accommodation
Adult Protection
Please describe the decision:
For Long Term Accommodation, what is the projected discharge date?
IMCA Referral Form – September 2011
Registered Charity 1076630
Limited Company 3798884
Care Review
Page 2 of 5
E
Date decision need to be made by:
F
Meeting dates (please specify)
Capacity Assessment
Name and position of the profession who had decided the referred person lacks mental capacity
to make a decision on the referral issue:
Has a 2 stage functional assessment of
capacity been carried out?
G
Yes
No
Family and Friends
Yes
Does the referred
person have a family?
No
And/or friends?
Yes
No
Are the person’s family appropriate to be involved in the best
interest decision?
Yes
No
If no, what is
the reason
the family are
not involved?
Risk and Support Needs
H
Support Needs - Please detail any support needs the advocate will need to provide advocacy
support e.g. Language or preferred communication methods:
IMCA Referral Form – September 2011
Registered Charity 1076630
Limited Company 3798884
Page 3 of 5
I
Risks - Please detail any information needed to ensure the safety of the advocate and the
referred person during the advocacy process:
Key People
J
Professional making the best
interest decision:
Referrer (if different from decision
maker)
Print Name
Position
Organisation
Tel No
Mobile No
Fax No
Email
Pager
K
Involved
professionals (not
listed above) and
contact details
L
Is the referred person aware of the advocacy referral?
M
Signature (Referrer)
N
Signature (Decision Maker)
O
PLEASE RETURN THE
COMPLETED FORM TO:
No
Date:
VoiceAbility, McMillan House, Worcester Park, Surrey, KT4 8RH
IMCA FAX: 0208 330 6622
Email: [email protected]
IMCA Referral Form – September 2011
Registered Charity 1076630
Yes
Limited Company 3798884
Page 4 of 5
Equal Opportunities
Do you consider yourself:
Male
Transgender
Female
Prefer not to say
How would you describe your ethnic origin or background?
White British
English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background, write in
Mixed and
Multiple Ethnic
Groups
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / multiple ethnic background, write in
Asian / Asian
British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background, write in
Black / African/
Carribean / Black
British
African
Caribbean
Any other Black / African / Caribbean background, write in
Other Ethnic
Group
Arab
Any other ethnic group, write in
IMCA Referral Form – September 2011
Registered Charity 1076630
Limited Company 3798884
Page 5 of 5
How would you describe your sexuality?
Heterosexual / Straight
Homosexual /
Gay/Lesbian
How would you describe your religious beliefs?
Bi-sexual
Prefer not to say
No Religion
Jewish
Christian
Muslim
Buddhist
Sikh
Hindu
Any other religion, please specify
Prefer not to say
Do you consider yourself to have?
A Learning Disability
Mental Ill Health
A Physical Disability
A Sensory Impairment
Dementia
Autism
An Acquired Brain Injury
Dementia
Physical Ill Health
Other (Please specify)
Prefer not to say
IMCA Referral Form – September 2011
Registered Charity 1076630
Limited Company 3798884