Children & Families Fact Sheet

GCCSSCN02 Name: PRN: DOB: Community and Adult Care Directorate [DOCUMENT COLOUR: WHITE] ** IMCA Services Referral Form IMCA Ref No. IMCA

CCP in partnership with Advocacy Trust Gloucestershire provides an Independent Mental Capacity Advocate to represent and support people who meet all the following criteria;

1. The person referred lacks capacity to make a decision concerning: a. serious medical treatment or b. long term care and health moves (more than 28 days in hospital /8 weeks in a care home), or c. residential care reviews, and they have no appropriate family or friends to represent them

2. The person referred lacks capacity and is subject to an adult protection case, whether or not appropriate family, friends or others are involved

Referrals can be made by telephoning 0800 644 6448 between 9am and 5pm Monday to Friday.

GCCSSCN02 April 2011 Name of client Date /name usually known by Date of birth

Gender Address Telephone no.

Postcode

White White Black White/black White/Asian Bangladeshi Indian Chinese British Irish Caribbean Caribbean

Other white Black Other black White/black Other mixed Pakistani Other Asian Other Ethnic group background African background African background background

Primary communication English Another spoken language? Gestures/vocalisations/facial expressions

Pictures/symbols/Signs BSL Other No obvious communication

What is the understanding Lacks capacity to make this For the foreseeable future At this time of the person’s capacity to decision make this decision?

On what basis was the Decision-maker’s judgement Assessment by another Other decision about the professional persons capacity made?

Client group/ reason for Learning disability Autistic Spectrum Disorder Mental Health Serious physical illness

GCCSSCN02 April 2011 lacking capacity

Dementia Acquired brain injury Unconscious Other

What is the decision to be Accommodation Serious Medical Care Review Adult Protection DoLs made about? Treatment

When does the decision need to be made by? When are any deadlines or important meeting dates?

Where is the person currently staying? Own home Care/nursing General Psychiatric Uncertain Other home hospital hospital

What is the decision-maker’s recommended course of action?

Are there any family/friends? yes No Uncertain

If there are family, friends etc., why is an IMCA needed? Names and contact details of GP and GP CARE MANAGER/SOCIAL WORKER Care Manager (if relevant), and anyone else who may be able to indicate the wishes of the person who lacks capacity KEY WORKER/Manager e.g. Manager of home, speech therapist, care staff, nurses, or any other significant person.

GCCSSCN02 April 2011 Any other relevant information.

Name and position Telephone . of referrer Address

Email Mobile

Is the referrer the YES NO decision maker? If not, give the name Name and position of Telephone and contact details decision maker of the decision maker

Address Email

GCCSSCN02 April 2011 County Community Projects, Cheltenham 1st Stop, 305 High Street, Cheltenham GL50 3HW Telephone: 0800 644 6448 Email: [email protected] Fax: 01242 776060

GCCSSCN02 April 2011