Lamplight API response

Any other phone numbers

Any other relevent addresses

If date of birth not completed

What pronouns - how should we address you? (She/her, He/him, They/them, I prefer not to say)

Will an interpreter be required

Do you/they have any communication needs?

Where did you hear about Connected Voice Advocacy

Does the person have the mental capacity (understand, retain, consider, communicate and recall) to instruct an advocate on this subject?

Are there any urgent meetings planned?

Please give details of any urgent meetings

Are you/they at risk of harm or abuse (safeguarding concerns)

Please detail any safeguarding issues

GP/Doctor first name

Medical Consultant (if any)

Medical Consultant's first name

Medical Consultants last name

Medical Consultant's address

Medical Consultant's postcode

Medical Consultants phone number

Medical Consultants email

Social worker / Care coordinator

Social care worker / Care coordinator first name

Social care worker / Care coordinator last name

Social care worker / Care coordinator address

Social care worker / Care coordinator postcode

Social care worker / Care coordinator phone

Social care worker / Care coordinator email

Tell us more about the person wanting advocacy. This is optional and anything you tell us will help us understand our community so we can meet needs more effectively.

Is your/their gender at birth, the same as now?

Types of disability

Sexuality

Asexual

Bisexual

Gay man

Heterosexual/straight

Lesbian

Prefer not to say

Queer

Questioning

In another way (please describe below)

Ethnic origin, further details if requested

Country of origin / cultural identity

By signing here I agree that Connected Voice can store this information that I have shared about me. I know it will be stored securely and I can ask to see it anytime.

Please write name here to agree to this.

Please check that you have completed all necessary fields and provided ALL necessary information.

If you are completing this form for yourself complete this box below and then scroll down to "submit"

Are you making this referral about yourself, or for someone else?

Do we have consent to contact?

If you are completing on behalf of someone else

Referrer mobile number

Referrer relationship to person being referred

If making the referal for someone else, do they consent to the referral?

If the person lacks mental capacity to accept/decline advocacy support, please confirm that you are referring in their best interests (it would be good practice to inform the person of the referral where possible)

Date mental capacity assessment carried out

We'll be in touch for a copy of assessment

Other key people involved in the referral, if any

Risk information

No known risk

Risk of harm due to medication/medical conditionRisk of deliberate self-harm

Risk of suicideRisk of severe self-neglect

Risk of domestic violence/abuseRisk of adult abuse

Risk of violence/harm to othersRisk to a child

Risk to staffRisk of exploitation

Risk of radicalisation

Risk information details

Advocacy service referring to

Independent Mental Health Advocacy (Detained patients)

Is the person detained under the Mental Health Act?

Is the person a conditionally discharged restricted patient?

Is the person subject to Supervised Community Treatment (SCT)?

Is the person subject to guardianship?

Please state section of the Mental Health Act

Qualifying patients: Informal Patients

Is the person an Informal Patient and discussing the possibility of being given Section 57 treatment?

Is the person under 18 and being considered for electro-convulsive therapy (ECT)?

Independent Mental Capacity Advocacy (IMCA)

The decision to be made in this case relates to

Serious medical treatment

Change of accommodation:

NHS body or local authority is proposing to arrange accommodation (or a change of accommodation) in hospital or a care home, and

Care Review in relation to accommodation where the person would benefit from an IMCA

Safeguarding Adults proceedings for an alleged perpetrator who lacks mental capacity (the person may have family and still be eligible for IMCA in this instance)

Please provide a brief summary

Decision Maker’s confirmation (CVA cannot accept an IMCA referral until we have received the following)

I confirm that I am the Decision Maker for this issue

I confirm that I deem this person to be un-befriended, with no-one appropriate to consult regarding this decision (unless this is a safeguarding issue)

I confirm the person being referred has been deemed to lack mental capacity to make this decision

I confirm that a mental capacity assessment for this decision was done

We'll be in touch to request a copy

Decision Maker’s details (if the Decision-Maker is also the referrer, please do not fill in these details)

Independent Care Act Advocacy (ICAA)

Issue that independent advocacy is required for (we can only accept referrals for adults for the issues below):

Needs assessment

Carer’s assessment

Preparation of a support plan or care and support plan

Review of a support plan or care and support plan

Safeguarding enquiry

Safeguarding review

Any additional information

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Other information

Select GP/Doctor