Before filling in this form, we have some information and guidance about what our Independent Mental Capacity Advocacy (IMCA) service does. One is an overview of what IMCA is and the other is guidance on who it is appropriate to consult with when making a referral.

To read both, please click on the buttons below.

    Part 1: Independent Mental Capacity Advocacy (IMCA) Referral

    Eligibility for an Independent Mental Capacity Advocate

    Change of Accommodation

    Providing, withholding or stopping Serious Medical Treatment

    Person lacks capacity to make this decision *

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

    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?

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

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


    Part 2: Referral Information

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


    YesNoNot yetPerson lacks understanding or awareness

    5. Referrer details

    6. Risk Issues


    7. Other relevant information about the person requiring advocacy

    YesNoDon't KnowPrefer not to say

    Acquired brain injuryAutistic Spectrum ConditionBlind/partially sightedCarerCognitive impairmentDeafDementiaLearning disabilityLong-term health conditionMental health needsOlder person (frailty)Physical condition/illness

    Word Referral Form

    If you are having issues with our online referral form, we have a version of it in Microsoft Word. To make a referral this way, please download the document by clicking on the button below, complete it and email it to [email protected]. Please also get in touch if you have any questions about the referral form.