Referral form for someone else

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Referral form for someone else

Step 1 of 7

14%

Unique ID

Does the person you would like to refer know you are making this referral?(Required)

Yes, they are aware and have consented.

They do not have capacity to consent to the referral but I am making a best interest decision to refer.

They do not know.

We cannot accept a referral without either the person’s consent or confirmation that you are making the referral in their best interests (as per the Mental Capacity Act).

About the person you would like to refer

Name(Required)

Date of Birth(Required)

Day

Month

Year

Current Address(Required)

Address Line 1 Address Line 2 City County Postcode

Permanent Address (If different)

Address Line 1 Address Line 2 City County Postcode

Which local authority area is the person currently in?(Required)

Referrals must be submitted via the Sheffield Advocacy Hub please visit: Sheffield Advocacy Hub

Other

They are currently living in(Required)

Their own home

Residential or nursing home setting

Supported living

Hospital

Other

They are currently in

Contact Phone Number

No phone number

Email Address (if applicable)

Enter Email Confirm Email

Does the person have any specific communication needs?(Required)

Yes

Please tell us more (e.g. BSL user, would need information in Easy Read format, would not be able to speak on the phone)

About you

Your name(Required)

Your Email(Required)

Enter Email Confirm Email

Your phone number(Required)

Your place of work(Required)

Please tell us if there are any regular days you would not be available to discuss the referral (e.g. if you do not work on Mondays)

1. Do you know what type of advocate you want to make a referral for?(Required)

1.1 IMCA

1.2 Care Act Advocate

1.3 IMHA

1.4 NHS Complaints

1.5 General Advocacy

1.6 Parenting Advocacy

1.7 Rule 1.2 Representative

Not sure

Please note, IMCA referrals can only be made for people who lack capacity to make a decision about where they live, or receiving serious medical treatment

1.1.1 Has the person been assessed as lacking capacity to make a decision about the referral issue.(Required)

Yes – please give details

Date of Assessment(Required)

Day

Month

Year

1.1.2 Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members)(Required)

Yes – please give details

Please note, IMCA referrals can only be accepted where there is no-one suitable to be consulted about the decision in the person’s life (e.g. no family or friends).

1.1.2 Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members) (Details)(Required)

1.1.3 What is the decision to be made for the person?(Required)

Where the Person Lives

Serious Medical Treatment e.g. surgery, cancer treatment, DNACPR

1.2.1 Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members)(Required)

Yes – please give details

1.2.1 Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members) (Details)(Required)

1.2.2 Do you think the person has substantial difficulty in participating in the decision or process (this means they have difficulty in weighing up or remembering information, or difficulty in communicating their views and wishes)(Required)

Yes

1.2.3 What does the person need advocacy support with?

Needs Assessment

Care and Support Planning

Care Review

Safeguarding

Transition to Adult Services

Carers Assessment (including for a young carer)

Other “please give details”

1.2.3 details(Required)

1.2.4 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – please give details

1.2.4 details

1.3.1 Under Which Section of the Mental Health Act is the person subject to compulsion?(Required)

1.3.2 Start date of section

Day

Month

Year

1.3.2 unknown

unknown

1.3.3 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – please give details

1.3.3 detail(Required)

1.4.1 Please tell us the details of the complaint (including whether a complaint has already been made to the NHS/Social Care)(Required)

1.4.2 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – please give details

1.4.2 details

1.5.1 Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members)(Required)

Yes – please give details

1.5.1 Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members) (Details)(Required)

1.5.2 Please tell us about what the person needs advocacy support with(Required)

1.5.3 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – please give details

1.5.3 details(Required)

1.6.1 What advocacy support is needed?(Required)

First ChoiceSupport at a Child Protection Case Conference

Support at Core Group Meetings

Support at Child in Need Meetings

Support with PLO (Public Law Outline) Meetings

Support with assessments (e.g. PAMs assessment)

Support with court processes

Other (please give details)

1.6.1 details(Required)

1.6.2 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – please give details

1.6.2 details(Required)

1.7.1 Has the person been assessed as lacking capacity to make a decision about their care and support?(Required)

Yes – please give details

1.7.1 Date of assessment(Required)

Day

Month

Year

1.7.2 Do you need the 1.2 Rep to complete either the CoP24 or CoP11?(Required)

Yes

1.7.3 Has the person had a recent needs assessment/care review (within the last 3 months)?(Required)

Yes

1.7.4 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – please give details

1.7.4 detail(Required)

2. Do you know what type of advocate you want to make a referral for?

2.1

2.1 They are detained in hospital under the Mental Health Act or on a CTO

2.1.1 Which section of the Mental Health Act is the person subject to (please include the start date)(Required)

Section 3

Section 37/41

Section 37/49

Community Treatment Order

Conditionally Discharged Restricted Order

2.1.2 Start Date(Required)

Day

Month

Year

2.1.3 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.2

2.2 Needs Assessment under the Care Act

2.2.1 Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members)(Required)

Yes – please give details (with a text box)

3b. Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members) (Details)

2.2.2 Do you think the person has substantial difficulty in participating in the decision or process (this means they have difficulty in weighing up or remembering information, or difficulty in communicating their views and wishes)(Required)

Yes

2.2.3 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.3

2.3 A review of their care and support needs

2.3.1 Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members)(Required)

Yes – please give details (with a text box)

2.3.2 Does the person have anyone else who could support them to be involved in the decision or process (e.g. friends or family members) (Details)

2.3.3 Do you think the person has substantial difficulty in participating in the decision or process (this means they have difficulty in weighing up or remembering information, or difficulty in communicating their views and wishes)(Required)

Yes

2.3.4 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.4

2.4 They may need to move somewhere else

2.4.1 Has the person been assessed as lacking capacity to make the decision themselves (about where they live or having medical treatment)?(Required)

Yes assessment completed on

Assessment pending

2.4.2 Assessment completion date(Required)

Day

Month

Year

2.4.3 Does the person have any friends or family who are not appropriate to consult about the decision?(Required)

Yes (please give details)

2.4.4 Details

2.4.5 Are you the decision maker under the Mental Capacity Act(Required)

Yes

No (please give name and contact details of the decision maker)

2.4.6 Name(Required)

2.4.7 Address(Required)

2.4.8 Contact Phone Number(Required)

2.4.9 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.5

2.5 They may need some serious medical treatment

2.5.1 Has the person been assessed as lacking capacity to make the decision themselves (about where they live or having medical treatment)?(Required)

Yes assessment completed on

Assessment pending

2.5.2 Assessment completion date(Required)

Day

Month

Year

2.5.3 Does the person have any friends or family who are not appropriate to consult about the decision?(Required)

Yes (please give details)

2.5.4 Details

2.5.4 Are you the decision maker under the Mental Capacity Act(Required)

Yes

No (please give name and contact details of the decision maker)

2.5.5 Name(Required)

2.5.6 Address(Required)

2.5.7 Contact Phone Number(Required)

2.5.8 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.6

2.6 They want to make a complaint about the NHS

2.6.1 Please tell us as much information as you can about the complaint the person wishes to make(Required)

2.6.2 Please tell us what support the person needs to make their complaint (select as many as apply)(Required)

Support at meetings

Support to write letters

Support to understand their options

Support to understand the complaints process

2.6.3 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.7

2.7 They want to make a complaint about social care

2.7.1 Please tell us as much information as you can about the complaint the person wishes to make(Required)

2.7.2 Please tell us what support the person needs to make their complaint (select as many as apply)(Required)

Support at meetings

Support to write letters

Support to understand their options

Support to understand the complaints process

2.7.3 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.8

2.8 They are a parent whose child is going through child protection proceedings

2.8.1 What support is needed from the advocate?(Required)

Support at Child in Need meetings

Support at PLO meetings

Support at Core Group meetings

Support with parenting assessments

Support at court proceedings

2.8.2 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.9

2.9 There are safeguarding concerns

2.9.1 Has a Section 42 Safeguarding Enquiry been started?(Required)

Yes

2.9.2 Is the person who you are referring the person who is at risk or the person alleged to have caused harm?(Required)

Person at risk

Person alleged to have caused harm

2.9.3 What is needed from the advocate?(Required)

Completion of CoP24

Acting as 1.2 rep once the DoL is authorised

2.9.4 What is the date of the person’s most recent needs assessment or review of care and support needs?(Required)

Day

Month

Year

2.9.5 What is the timeframe in which the application is expected to be submitted to the Court of Protection?(Required)

Within a week

1-4 weeks

1-2 months

Longer

2.9.6 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.10

2.10 Support around a Deprivation of Liberty in a supported living setting/their own home

2.10.1 What is needed from the advocate?(Required)

Completion of CoP24

Acting as 1.2 rep once the DoL is authorised

2.10.2 What is the date of the person’s most recent needs assessment or review of care and support needs?(Required)

Day

Month

Year

2.10.3 What is the timeframe in which the application is expected to be submitted to the Court of Protection?(Required)

Within a week

1-4 weeks

1-2 months

Longer

2.10.4 Are there any other issues or areas where advocacy support is needed?(Required)

Yes – go back to question 2

2.11

2.11 Other

2.11.1 Please tell us about the issue where the person needs advocacy support(Required)

3. Are there any planned meeting dates that we need to be aware of? Wherever possible, we would ask that dates for meetings where an advocate is required are discussed with the advocate to ensure their availability.

4. Are there any risk issues pertaining to the person themselves, their physical environment or their family or friends?(Required)

If there is no information to add, please type n/a into the box.

5. Is there anything else you would like to tell us regarding this referral?

We support lots of people with lots of different needs from lots of different cultures, communities and groups. We want to make sure we are supporting people in the best way we can.We ask for information about the person you are referring so that we can make sure we meet their needs and understand what’s important to them. We want to understand more about who accesses our services, and who doesn’t. This helps us make our services better. It also helps us target our work to people who might benefit from our services, but aren’t using them at the moment.We have a legal responsibility to keep this information safe and confidential.

6. Which of the following best describes the person’s gender?(Required)

Male

Female

Non-binary

Prefer not to say

Another term (please tell us)

Gender Term

7. Do they consider themselves to be a trans person (this is a term to describe people whose gender is not the same as the sex they were assigned at birth)(Required)

Yes

Prefer not to say

8. Do they have a disability, long-term health condition or any additional needs?(Required)

Visual impairment

Learning disability

ADHD

Dementia

Physical disability/mobility issues

Deaf/hearing impairment

Learning difficulty

Autism

Mental Health Needs

Stroke survivor

Other

Other additional needs

9. Which of the following best describes their ethnicity?

9a. White

British

Irish

European

Gypsy/Irish Traveller

Roma

White – Other

White – Other (please tell us)

9b. Mixed or Multiple Ethnic Groups

White & Black Caribbean

White and Black African

White and Asian

Mixed – Other mixed/multiple background

Mixed/multiple background (please tell us)

9c. Asian

Indian

Pakistani

Bangladeshi

Chinese

Asian – Other Asian background

Asian Other (please tell us)

9d. Black

Caribbean

African

Other Black, Black British, Caribbean or African

Black, Black British, Caribbean or African Other (please tell us)

9e. Other Ethnic Group

Arab

Any other ethnicity

Prefer not to say

Any other ethnicity (please tell us)

10. What is their preferred language?(Required)

11. How would the person describe their sexual orientation?(Required)

Heterosexual/Straight

Gay man

Gay woman/lesbian

Bisexual

Other

Prefer not to say

Other sexual orientation

12. What is their religious belief?(Required)

None/atheist

Christian

Buddhist

Muslim

Hindu

Agnostic

Prefer not to say