Independent Mental Health Advocacy Referral Form

Part 1: Independent Mental Health Advocacy (IMHA) Referral

Your email (required)

How did you hear about this service? (required)
—Please choose an option—CarerEvent/Information stallFamily/friendsPrevious ClientI've referred to the advocacy service beforeI've used the advocacy service in the pastTwitter/FacebookWebsite (Advonet)Website (other)Word of mouth

Date of referral (DD/MM/YYYY) (required)

1. Section Details

What section is the client under?

—Please choose an option—Section 2Section 3Section 37Section 37/41Section 47Conditionally discharged restricted patientCommunity Treatment Order? (CTO)Guardianship Order?Under 18 and being considered for ECT or a section 58a treatmentOther

If someone is in a Crisis Assessment Unit, they might also be eligible for an IMHA

Other: Please state

Section start date (DD/MM/YYYY)

Section expiry date (DD/MM/YYYY)

Name of Responsible Clinician (RC):

Contact details for RC (please provide direct contact details i.e. email address)

Date rights under Mental Health Act last read to client (DD/MM/YYYY):

2. Purpose of referral:

Is the referral by, or upon request of, the client?

YesNo

If "No", what is the advocacy need?

3. Details of Nearest Relative or any other relevant person e.g. close friend

Details of Nearest Relative (this is optional, unless the client is under 18)

Part 2: Referral Information

4. Relevant Person’s Details (the person who needs advocacy)

Your Name (required)

Ward/unit/current address (if different from your usual address)

Postcode

Home Address (where you usually live)

Postcode

Preferred contact method —Please choose an option—Contact a person who is helping meEmailLandline telephoneMobile phoneSkype/video callText

Enter your contact details here, e.g. email, mobile number or the contact details of the person who is helping you. (If you give us their contact details we will take this as consent that we can contact them to discuss your issue)

Current Phone Number

Can we leave a message?

YesNo

5. Risk Issues

Are there any current Risk Issues we need to be aware of? If Yes, please provide details below (e.g. restrictions etc.)

YesNo

6. Other relevant information about the person requiring advocacy

If you / the client has any support needs e.g. communication, please write them down in the box below

What is the person's first language?

Are there any additional communication or other needs not already mentioned e.g. needing advance notice of meeting dates/times?

The following information is collected to help us create equal opportunities for individual’s resident within our local communities. We use this information anonymously to identify if the diversity of the people accessing our services fully reflects the communities we serve. If you prefer not to answer please select that option.

Your Date of Birth - we ask for this information as some of our services are for specific ages (DD/MM/YYYY)

Gender
—Please choose an option—MaleFemaleTrans MaleTrans FemaleNon-binaryPerson referring doesn’t knowPrefer not to sayOther

Other: Please tell us

Is their gender the one they were assigned at birth?
YesNoDon't KnowPrefer not to say

Ethnicity
—Please choose an option—Asian/Asian British (Bangladeshi)Asian/Asian British (Chinese)Asian/Asian British (Indian)Asian/Asian British (Pakistani)Asian/Asian British (Other)Black/Black British (African)Black/Black British (Caribbean)Black/Black British (Other)Mixed: White/AsianMixed: White/Black AfricanMixed: White/Black CaribbeanMixed: OtherWhite (British)White (Irish)White (Other)OtherDon't knowPerson referring doesn't knowPrefer not to say

Other: Please tell us

Religion
—Please choose an option—BuddhistChristianHinduJewishMuslimSikhNo beliefNo religionOtherPerson referring doesn't knowPrefer not to say

Other: Please tell us

Sexuality
—Please choose an option—HeterosexualLesbianGayBisexualPansexualOtherPerson referring doesn't knowPrefer not to say

Other: Please tell us

Disability – for monitoring and equal opportunity purposes, please let us know if the client has any of the following disabilities/impairments by ticking the relevant boxes
Acquired brain injuryAutistic Spectrum ConditionBlind/partially sightedCarerCognitive impairmentDeafDementiaLearning disabilityLong-term health conditionMental health needsOlder person (frailty)Physical condition/illness

Is the client disabled in any other way not listed above? If so, please write in this box.

Glossary of Terms:
Non-binary refers to individuals who don’t see themselves as either male or female. Individuals identifying as non-binary may ask you to use gender neutral pronouns such as they/their rather than he/she. Please do not ask non-binary individuals the sex or gender assigned to them at birth as this is irrelevant.
Trans male/female refers to individuals who are transitioning to the gender they identify with.
Pansexual refers to individuals who are romantically, emotionally, sexually attracted to people regardless of their sex and gender identity.