Please the name and position of the professional who has assessed that the referred person lacks mental capacity to make a decision on the referred issue: Has a 2 stage functional assessment of Yes No capacity been carried out? G Family and Friends Does the referred Yes No And/or friends? Yes No person have a family? Are the person’s family/friends appropriate to act in that persons Yes No best interest? If no, please outline the reason Risk and Support Needs H Support Needs - Please detail any support needs the advocate needs to be aware of to provide advocacy e.g. Any long term condition, Impairment, Language or preferred communication methods: I - Please detail any information needed to ensure the safety of the advocate and the referred person during the advocacy process: Key People J Professional making the best Referrer (if different from Decision interest decision (Decision Maker): Maker)
Please the name and position of the professional who has assessed that the referred person lacks mental capacity to make a decision on the referred issue: Has a 2 stage functional assessment of capacity been carried out? Yes No G Family and Friends Does the referred person have a family? Yes No And/or friends? Yes No Are the person’s family/friends appropriate to act in that persons best interest? Yes No If no, please outline the reason Risk and Support Needs H Support Needs - Please detail any support needs the advocate needs to be aware of to provide advocacy e.g. Any long term condition, Impairment, Language or preferred communication methods: I - Please detail any information needed to ensure the safety of the advocate and the referred person during the advocacy process: Key People J Professional making the best interest decision (Decision Maker): Referrer (if different from Decision Maker)
Doncaster_IMCA_Referral_Form_November_2017.docx