Please note that this advocacy referral form is for these services:

If you want to make a referral to our Leeds Autism AIM service, please click here.

    This referral form is for all types of advocacy. You can complete this form on your own behalf (self-referral) or on behalf of someone else. Parts 1 and 2 must be completed as a minimum. Then, depending on the advocacy required, please complete other relevant parts. Incomplete forms may result in delays in allocating an advocate.

    Data entered on this page will be stored by The Advonet Group on our secure database. Do you consent to this?

    Part 1: Type of Advocacy Required

    Advocacy required:

    How did you hear about this service?

    Date of referral:

    Part 2: Referral Information

    1. Relevant Person’s Details: (this is the person who needs advocacy)

    Name:

    Home (usual) Address:

    Current Address or Location:

    Preferred contact method:

    Email address:

    Contact number:

    Can we leave a message?

    Date of birth:

    Gender:

    Is your gender the one you were assigned with at birth?

    Ethnicity:

    Religion:

    Sexuality:

    Consent to make a referral for advocacy:

    Name of person giving consent:

    2. Reason for advocacy referral? (Please include a summary of the advocacy issue/decision being made, upcoming meeting dates, deadlines, priority areas etc)

    Reason for referral:

    3. Referrer Details:

    Referrer Name:

    Job Title:

    Employer:

    Secure email:

    Tel. No.:

    Place of work (including address)

    4. Friends and/or family: (Is there an appropriate person to support the person’s involvement?)

    Is there anyone (e.g. friend/relative) who you are consulting with?

    What is their relationship to the person requiring advocacy?

    What are their contact details?

    Are there any current Risk Issues we need to be aware of?

    Type any risk issues in this box:

    5. Other relevant information about the person requiring advocacy.

    Any support needs?

    Other support needs?

    Is the person a carer?

    How does the person communicate?

    What is the person’s first language?

    Other relevant information?

    Part 3: Independent Mental Capacity Advocacy (IMCA)

    6. What is the main reason for this referral?

    Has a capacity assessment been carried out?

    Enter date of capacity assessment if applicable:

    Please confirm that there are no people, (other than paid people) who are appropriate to consult with?

    7. Please indicate the Serious Medical Treatment you are considering:

    Other medical treatment:

    Will the proposed procedure involve a General Anaesthetic (GA)?

    Is the person currently an inpatient?

    Hospital:

    Ward/Direct Telephone Number:

    8. Decision Maker Details (if the referrer is the decision maker, please tick this box)

    Part 4: Deprivation of Liberty Safeguards (DoLS)

    Main reason for referral:

    Has a DoLS application been made for the person requiring advocacy?

    Does the person have a Relevant Person’s Representative? (RPR):

    Please write any other relevant information here e.g. DoLS start date, RPR contact

    Part 5: Care Act Advocacy Referrals (CAA)

    9. Is the person going through a social care process? Please select main process below.

    Does the person requiring advocacy have substantial difficulty in engaging with, or understanding the referral issue? (these are: difficulty understanding, retaining, using / weighing up information or communicating their wishes and feelings):

    Does the person requiring advocacy have an appropriate person to support them?

    Part 6: Independent Mental Health Advocacy (IMHA)

    If the patient is an informal (voluntary) patient, please make a referral for Community Advocacy.

    10. Qualifying Patient.

    The person is detained under the Mental Health Act 1983.

    Section Start Date (DD/MM/YYYY):

    Type of Section:

    11. Additional Contacts: (Responsible Clinician (RC) / Nearest Relative etc):

    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.

    If you are having problems sending a referral using this form, please download the Word version by clicking on the button below. Then, once completed, please send it to [email protected].