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IMCA referral form

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Independent Mental Capacity Advocacy (IMCA) Referral Form

The role of an IMCA is defined in the Mental Capacity Act 2005 (amended 2019) and before we can assign an IMCA certain specific information must be provided.

A failure to provide this required information can lead to a rejection in the referral and/or delay in an IMCA being appointed.

You will receive an automated acknowledgement of your referral on the same day, or within a working day.

The referral will then be checked to ensure all required information is included prior to allocation, and you will be notified who this is. The advocate will make contact so you have their details.

It is your duty to ensure that the required information is supplied and if you are the Decision Maker you have a statutory duty to engage with the allocated IMCA.

Two of the extension functions for IMCAs included in the Act have now largely been replaced by (non-instructed) Care Act Advocacy i.e. annual care (accommodation) reviews and safeguarding.
Please consider if it is more appropriate to use this service.

If you need support to complete this form, please contact us on 0151 347 8183.

Section A : About the person

Name of person

First name

Middle name

Last name

Date of birth

Current place of residence

NHS Number / Social Care Number

Telephone number

Equal opportunities form completed?

Yes

Section B: What is the Best Interest Decision? (Please tick)

What is the Best Interest Decision?

Serious Medical Treatment

Long Term Accommodation

For Long Term Accommodation, what is the projected discharge date?

Review or Enquiry

For Care review complete ‘Care act’ referral form

For Safeguarding enquiry complete ‘Care Act’ referral form

Please describe the decision options with relevant detail, any proposed dates or deadlines and contact details for anyone who may be appropriate to consult about the decision:

Date the decision needs to be made by?

Any other deadlines/ meeting dates (please specify including dates):

Section C: Capacity Assessment

Has capacity assessment been completed?

Yes

Name of assessor

Designation

(e.g. Social Worker)

Date of assessment

Section D: Family and Friends

Does the referred person have a family?

Yes

Does the referred person have any friends?

Yes

Are the person’s family appropriate to be involved in the best interest decision?

Yes

If no, what is the reason the family are not involved?

Section E: Risks and Support needs

Risks: Please detail any information relevant to ensuring the safety of the person or of the advocate (or both):

Support Needs: Please detail any support needs the advocate will nee to provide support e.g. Language or preferred communication methods:

Safeguarding: Please detail any existing safeguarding concerns that the advocate should be aware of:

Section F: Key People

Name of Professional making the best interest decision:

Position

Organisation

Telephone

Mobile

Email address

Confirm referrers email address

Fax No:

Pager

Referred (if different from decision maker)

Position

Organisation

Telephone

Mobile

Fax No:

Pager

Involved professionals (not listed above) and contact details:

Is the referred person aware of the advocacy referral?

Yes

Leave this field blank

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