Independent Mental Capacity Advocacy referral

Devon and Torbay

Independent Mental Capacity Advocacy (IMCA) Service

REFERRAL FORM

Before completing this Referral form  

  • Please phone the IMCA service to discuss the referral on 0845 231 1900 or read the Referral Guidance notes  on the website
  • Identify the Decision Maker, i.e. the person responsible for making the final decision.  For example, it is usually the Consultant/GP for Serious Medical Treatment or the Care Manager for Change of Accommodation.  The Decision Maker must give permission for this referral to be put forward.
  • Ensure that the person’s mental capacity has been assessed for this particular decision– it should be time and decision specific.   Specify who assessed the person’s capacity, when and where this is recorded.
  • Establish that the client is unbefriended – e.g. there are no family or friends who are willing to be involved or appropriate to consult in the Best Interest decision.
  • If the referral is for safeguarding decisions, ensure that a Mental Capacity Assessment has been completed for each ‘Protective Measure’.  If Change of Accommodation is a  protective measure, this will require a separate referral.  (The IMCA service are happy to complete this for you if there is a supporting e-mail from the Decision Maker requesting this instruction)

Devon and Torbay Independent Mental Capacity Advocacy (IMCA) Service
REFERRAL FORM

If you do not have a postcode, please leave this as 'none'.
Where the client is now
Referrer Details
Decision Maker
The Decision
If decision is regarding a Change of Accommodation
Assessment of mental capacity
Additional Contact 1
Other people (e.g. GP), (friends, family, if SoA) who may be able to indicate the wishes of the person being referred
Additional Contact 2
Other people (e.g. GP), (friends, family, if SoA) who may be able to indicate the wishes of the person being referred
Additional Contact 3
Other people (e.g. GP), (friends, family, if SoA) who may be able to indicate the wishes of the person being referred
Additional Contact 4
Other people (e.g. GP), (friends, family, if SoA) who may be able to indicate the wishes of the person being referred

*required fields