This is a referral form for our Independent Mental Health Advocacy (IMHA) service. Our IMHAs support people who are detained under the Mental Health Act, providing free, independent and confidential advocacy support.

If you would like to make a referral, please complete the form below

    Part 1: Independent Mental Health Advocacy (IMHA) Referral

    1. Section Details

    2. Purpose of referral:


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

    Part 2: Referral Information

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


    5. Risk Issues


    6. 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.