IMHA Referral Form - CADMHAS: Mental Health Advocacy Service

Date of Referral:

Type of Hospital (e.g. psychiatric):

Date of Admission:

Name of Service User:

Date of Birth:

Gender

Current Address (must include ward name, unit/hospital and postcode)

Service User's Home Address (include area/county and postcode)

Service User's Telephone Number:

Name of Referrer

Referrer Contact Number

Referrer Email Address

Form submission confirmation will be sent to this address

Service User's Preferred Language

Other language (if applicable)

Has service user used advocacy service before?

Has the service user requested an IMHA?

Has service user been informed of their rights?

Does the service user understand their rights?

Date Section Commenced:

Has the section already been appealed? (If yes, please give details)

Name of Responsible Clinician:

Name of Care Co-ordinator (if applicable)

Instruction:

Compulsory Instructed

Compulsory Non Instructed

Informal Instructed

Informal Non Instructed

Reason for Referral

Any meeting dates due

Any other relevant information:

Any risk