Independent Mental Capacity Advocacy Referral Form

Part 1: Independent Mental Capacity Advocacy (IMCA) Referral

Eligibility for an Independent Mental Capacity Advocate

Eligibility is set out in Chapter 10 of the Mental Capacity Act Code of Practice as follows. Please select to confirm eligibility.
NB To be completed by a medical or social care professional only. If you need assistance, please call The Advonet Group on 0113 244 0606.

Decision:

Change of Accommodation

or

Providing, withholding or stopping Serious Medical Treatment

Circumstances

Person lacks capacity to make this decision *

*Someone lacks capacity if they have an impairment of the mind or the brain AND (with regard to the specific decision to be made) are unable to:
- Understand information
- Retain information
- Weigh up pros and cons
- Communicate a decision
A person may have capacity but have substantial difficulty. Please see our Care Act Referral Form if there is a Social Care process for someone who has substantial difficulty.

There is no one appropriate available to support the person other than paid staff

Note – to progress to the next section of this form, you must choose one ‘decision’ and both ‘circumstances’.

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)

If the reason for referral is either a Care Review or Safeguarding, please make a Care Act Referral.

1. What is the main reason for this referral?

—Please choose an option—Change of Accommodation (CoA)Serious Medical Treatment (SMT)

Has a capacity assessment been carried out for this specific decision?
—Please choose an option—YesNo

If yes – does the person lack capacity for this decision?
—Please choose an option—YesNo

Date of capacity assessment (DD/MM/YYYY)

Please confirm that there are no other people (other than paid people) who are appropriate to consult with?
For guidance about who is appropriate to consult, click here
—Please choose an option—There are no other appropriate people we can consult withThere are other people (unpaid) involved but they are not appropriate to consult with and I have informed them of thisI don't know if there are other people involved we can consult with

Names and contact details of key contacts

2. For a change of accommodation IMCA, please complete the following:

Brief reason for referral and options to be considered:

Name of the Decision Maker (if not the referrer):

Email and phone number of Decision Maker

Email and phone number:

Or
Decision maker has not been identified - please explain why below

Please explain why below

3. For a Serious Medical Treatment IMCA, please complete the following:

(Where the treatment proposed has finely balanced benefits and burdens, or there is a finely balanced choice of treatments, or what is proposed is likely to have serious consequences for the patient).

Please indicate the Serious Medical Treatment you are considering providing, withholding or stopping:

Treatment involves a General Anaesthetic

The person is currently an inpatient

Hospital:

Ward / Direct Telephone Number:

The person is currently in the Leeds City Council area (somewhere that pays council tax to Leeds)*
*If this is an outpatient who is being referred to a hospital outside of Leeds but they are in Leeds at the time of the referral, we would accept this – tick the box

Yes

Name of the Decision Maker:

Email and phone number:

Or
Decision maker has not been identified - please explain why below

Please explain why below

Part 2: Referral Information

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

Name (required)

Current Address/ward/unit (if different from the person's usual address)

Postcode

Home Address (where the person usually lives)

Postcode

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

Current Phone Number

Can we leave a message?

YesNo

Is the relevant person aware this referral is being made?

YesNoNot yetPerson lacks understanding or awareness

5. Referrer details

Please tell us a bit more about yourself

Role/Job Title

Employer
—Please choose an option—AdvonetLeeds City CouncilLeeds Community Healthcare NHS TrustLeeds Teaching Hospitals TrustLeeds and York Partnership Foundation TrustVoluntary OrganisationOther

Place of work, including address

Phone number

Secure email (if applicable)

6. 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

7. 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.