<p> GCCSSCN02 Name: PRN: DOB: Community and Adult Care Directorate [DOCUMENT COLOUR: WHITE] ** IMCA Services Referral Form IMCA Ref No. IMCA </p><p>CCP in partnership with Advocacy Trust Gloucestershire provides an Independent Mental Capacity Advocate to represent and support people who meet all the following criteria;</p><p>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</p><p>2. The person referred lacks capacity and is subject to an adult protection case, whether or not appropriate family, friends or others are involved</p><p>Referrals can be made by telephoning 0800 644 6448 between 9am and 5pm Monday to Friday.</p><p>GCCSSCN02 April 2011 Name of client Date /name usually known by Date of birth</p><p>Gender Address Telephone no.</p><p>Postcode</p><p>White White Black White/black White/Asian Bangladeshi Indian Chinese British Irish Caribbean Caribbean</p><p>Other white Black Other black White/black Other mixed Pakistani Other Asian Other Ethnic group background African background African background background</p><p>Primary communication English Another spoken language? Gestures/vocalisations/facial expressions</p><p>Pictures/symbols/Signs BSL Other No obvious communication</p><p>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?</p><p>On what basis was the Decision-maker’s judgement Assessment by another Other decision about the professional persons capacity made?</p><p>Client group/ reason for Learning disability Autistic Spectrum Disorder Mental Health Serious physical illness</p><p>GCCSSCN02 April 2011 lacking capacity</p><p>Dementia Acquired brain injury Unconscious Other </p><p>What is the decision to be Accommodation Serious Medical Care Review Adult Protection DoLs made about? Treatment</p><p>When does the decision need to be made by? When are any deadlines or important meeting dates?</p><p>Where is the person currently staying? Own home Care/nursing General Psychiatric Uncertain Other home hospital hospital</p><p>What is the decision-maker’s recommended course of action?</p><p>Are there any family/friends? yes No Uncertain </p><p>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.</p><p>GCCSSCN02 April 2011 Any other relevant information.</p><p>Name and position Telephone . of referrer Address</p><p>Email Mobile</p><p>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</p><p>Address Email</p><p>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</p><p>GCCSSCN02 April 2011</p>