IMCA Referral Form

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Who is entitled to an IMCA?

In accordance with the Mental Capacity Act 2005, referrals must be made for individuals in the following circumstances:

  • The person is aged 16 or over
  • A decision needs to be made in the person’s best interests about either a long-term change in accommodation or serious medical treatment
  • The person to be referred has been assessed as lacking capacity to make that specific decision at the time it needs to be made
  • The person does not have a family member or friend who is ‘appropriate to consult’.
  • The person has not executed a Lasting Power of Attorney for Health and Welfare
  • There is no Court of Protection appointed Deputy who continues to act on the person’s behalf in relation to health and welfare. NB if a person has only a Property and Finance LPA or Deputy in place, this would not prevent them from being referred for an IMCA.

Referrals may also be made for decisions concerning

  • Care Reviews, where there is no-one ‘appropriate to consult’ or
  • Adult Protection cases, whether or not family, friends or others are involved.

For all referrals to Gaddum Advocacy, there is a requirement that the individual lacking capacity is currently resident or receiving care or treatment in Manchester.

 

 

 

Details of person being referred
Address and postcode at time of referral (if different from home address)
Accessibility Information
Client Demographic Information
Risk Assessment
THE DECISION BEING MADE

 Ticked Safeguarding - Wherein a person who lacks capacity to be involved in safeguarding proceedings concerning them, please submit a Care Act Advocacy referral.

ADVOCACY NEEDS
CAPACITY ASSESSMENT

Independent Mental Capacity Advocacy is for people who have been assessed to lack capacity regarding a decision that is to be made about their accommodation or medical treatment. A capacity assessment must be complete before an Advocate is allocated. Please consider if a Care Act Advocacy referral may be more appropriate

REFERRER DETAILS
By completing this form you agree to Gaddum keeping this information stored on a secure electronic case recording system, computer, and paper filing system. You confirm you are providing this information and asking for this referral in the client’s best interests. You are confirming wherein the client has capacity to do so, you have sought consent for this referral.
Decision Maker (If different from referrer)
Under the Mental Capacity Act, we must seek instruction from the Decision Maker before processing this referral.