6 Stroke 16 Asperger’s Syndrome/High functioning 7 Parkinson's Autism 8 Motor Neurone Disease 17 Other Learning, Developmental or 9 Acquired Brain Injury Intellectual Disability 10 Neurological Other 18 Mental Health Condition - Dementia 19 Mental Health Condition - Other 20 No Relevant Long-Term Reported Health Conditions Details about Capacity, Consent and Advocacy 3 3.1 Does the adult Yes No concerned have the capacity to consent to (If ‘Yes’ please proceed to section 3.2, if ‘No’ please proceed to section sharing this information? 3.3.) 3.2 Does the adult Yes No concerned know you are (If ‘Yes’ please proceed to section 3.4, if ‘No’ please proceed to section sharing this information? 3.3) 3.3 Have you completed a Yes No mental capacity (If ‘Yes’ please proceed to section 3.5, if ‘No’ please proceed to section assessment? 3.6) 3.4 Have they consented? Yes No (If ‘Yes’ Please proceed to section 3.8, if ‘No’ please proceed to 3.9) 3.5 What was the outcome of the Mental The person has capacity (Please proceed to section 3.8) Capacity assessment? 3.6 Why has no mental capacity assessment been (Please proceed to section 3.9) undertaken? 3.7 Best Interest decision (if applicable): If applicable record (Please include any details of relationship to the adult) the advocate / IMCA details here: 3.9 Are you referring in Yes No the wider public’s (If ‘Yes’ please provide details in the space below, if ‘No’ please interest? consider why the referral is being made, contact 01619125135 if you would like to discuss this referral) Adult’s Outcome: 4 What would the adult like to happen following this referral?
6 Stroke 7 Parkinson's 8 Motor Neurone Disease 9 Acquired Brain Injury 10 Neurological Other 16 Asperger’s Syndrome/High functioning Autism 17 Other Learning, Developmental or Intellectual Disability 18 Mental Health Condition - Dementia 19 Mental Health Condition - Other 20 No Relevant Long-Term Reported Health Conditions Details about Capacity, Consent and Advocacy 3 3.1 Does the adult concerned have the capacity to consent to sharing this information? Yes No (If ‘Yes’ please proceed to section 3.2, if ‘No’ please proceed to section 3.3.) 3.2 Does the adult concerned know you are sharing this information? Yes No (If ‘Yes’ please proceed to section 3.4, if ‘No’ please proceed to section 3.3) 3.3 Have you completed a mental capacity assessment? Yes No (If ‘Yes’ please proceed to section 3.5, if ‘No’ please proceed to section 3.6) 3.4 Have they consented? Yes No (If ‘Yes’ Please proceed to section 3.8, if ‘No’ please proceed to 3.9) 3.5 What was the outcome of the Mental Capacity assessment? The person has capacity (Please proceed to section 3.8) 3.6 Why has no mental capacity assessment been undertaken? (Please proceed to section 3.9) 3.7 Best Interest decision (if applicable): If applicable record the advocate / IMCA details here: (Please include any details of relationship to the adult) 3.9 Are you referring in the wider public’s interest? Yes No (If ‘Yes’ please provide details in the space below, if ‘No’ please consider why the referral is being made, contact 01619125135 if you would like to discuss this referral) Adult’s Outcome: 4 What would the adult like to happen following this referral?
adult_safeguarding_concern_referral_form_jan_18.docx