Referral Form: Independent Advocacy under the Care Act

Which Local Authority is this for

LancashireTraffordSt Helens

Full Name

Date of birth *

Day

Month

Year

Permanent Address

City

Postcode *

Current location if different from permanent address:

Telephone Number *

Mobile Phone Number

Email Address *

please specify here0 / 150

How does the person communicate

EnglishOther spoken language, please specify:British Sign LanguageWords/pictures/MakatonGestures/expressions/vocalisationsNot listed, please specify:No obvious means of communication

please specify here0 / 150

Have you or any of your family served in the armed forces?

YesNo

Social Worker’s contact details:

Name *

Role

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone *

Fax

Issue to be addressed:

Assessment, review or care and support planningCarer’s assessment and reviewCHC assessment and reviewSafeguarding (Section 42 enquiry or safeguarding adult review)

Please provide further information below *

Substantial difficulty

I have reasonable belief that the person will have substantial difficulty with the process at this time but may become able again in the near futureI have reasonable belief that the person will have substantial difficulty with the process and will do for the foreseeable future

Has a capacity assessment been carried out?

YesNo

Outcome of the capacity assessment:

Family and friend involvement: Does the person have an appropriate adult willing and able to facilitate their involvement in the process/processes and does the individual consent to their involvement? If not, please provide further details:

Significant dates: Please provide details for any impending meetings or deadlines:

Further relevant information: Please provide details:

Does the person have capacity to consent to the referral?

YesNo

If yes, has consent been obtained? *

YesNo

Please provide details of any risk the Independent Advocate will need to consider:

Signature

Date

Day

Month

Year

I would like an Independent Advocate to do this work in accordance with the Care Act 2014

Signature

Date

Day

Month

Year

Referral Form

Independent Advocacy under the Care Act

Which Local Authority is this for

Disability or impairment:

Gender

Sexual Orientation

How does the person communicate

Ethnic Origin

Religion or belief:

Have you or any of your family served in the armed forces?

Issue to be addressed:

Substantial difficulty

Has a capacity assessment been carried out?

Does the person have capacity to consent to the referral?

If yes, has consent been obtained? *