IMCA Referral Form - CADMHAS: Mental Health Advocacy Service

Area

Date of Referral:

Reason for Referral (select ONE option only):

Serious Medical Treatment

Safeguarding Vulnerable Adults

Move of Accommodation - NHS Request

Move of Accommodation - Local Authority Request

Care Review - New

Care Review - Monitoring

Client Name:

Client Date of Birth:

Client Location (including postcode)

Client's Home Address (including postcode)

Client Contact Number:

Referrer Name

Referrer's Relationship to Client:

Referrer Address (including postcode)

Referrer Phone Number:

Referrer Email Address:

Has a full capacity assessment been completed with the client?:

Date of Assessment:

Name of Assessor:

Is the person's capacity likely to change?:

I confirm that the patient/client lacks capacity to give or withhold consent for the decision indicated because of an impairment or disturbance of the mind or brain affecting the way their mind or brain works (e.g. a disability, condition or trauma, or the effect of drugs and alcohol) and they cannot do one or more of the following:

understand the relevant information about the decision to be made,

retain that information in their mind for long enough to make a decision,

use or weigh that information as part of the decision-making process,

communicate their decision (by talking, using sign language or any other means)

Reason for referral/Background information:

Are there any family/friends?

Are they acting in the client's best interest?

Please give reasons why they are deemed not to be appropriate to be consulted or why they are not willing or able to be consulted in the decision making process.

Is there any risk the IMCA should be aware of when visiting the client, or any assistance required by the client (interpreter etc)?

If the client is in a hospital, independent hospital or other accommodation, please specify name of hospital and ward name

If the client has another communication method, please state here. Otherwise, type N/A

If "other" has been selected above, please state below. Otherwise, type N/A

ADDITIONAL CONTACTS - RELEVANT PEOPLE TO OBTAIN INFORMATION FROM. Other people involved e.g. Friends, family, LPA (Lasting Power of Attorney) GP, Care Home staff, Lead Nurse who may be able to indicate the wishes of the person being referred. Please include name, relationship and telephone number

Is there a date by which the decision must be made?

Is there a deadline for a course of action? (Best Interest / MDT Meeting)

Has a decision already been made about Serious Medical Treatment in an emergency?

Please include details below

We welcome your enquiries!