Care Act advocacy (ICAA)

Which London borough is the advocacy needed for?*
This is the borough which is responsible for the person's care
Nature of Care Act process
Care Act process*
Please select the primary reason why you are referring for ICAA
- Assessment, including carers and young carers
- Care and support planning
- Review of a care and support plan
- S42 safeguarding enquiry
- Safeguarding adults review
About the person being referred*
Please select one option below
- An adult with care and support needs
- A young person in transition, with care and support needs
- A carer with support needs
- A young carer with support needs
Does the person have substantial difficulty...
...understanding relevant information?
- Understanding relevant information
...retaining that information?
- Retaining that information
...using or weighing up that information?
- Using or weighing up that information
...communicating their views, wishes and feelings?
- Communicating their views, wishes and feelings
Please mark at least one of the four boxes above to confirm eligibility. You cannot continue to the next page without doing so*
Appropriate person
Is someone appropriate available to help the person?
- No one appropriate available to help the person
Reason for referral if appropriate help available*
If someone appropriate is available to help the person, please specify why you believe a referral for advocacy is required.

About the issue
Subject*
Description*
Cognitive impairment
Important or required date
If this referral requires action or a decision by a specific date, please enter it here
DD slash MM slash YYYY
Supporting documents
If you have documents that will help us to process this referral, such as a capacity assessment, please upload them here. Please be aware that the total size of all documents must not exceed 35MB
Upload files
if you have a mental capacity assessment and/or other relevant documents for this referral, please attach them here.
Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 35 MB, Max. files: 5.

About you, the referrer
Referrer's name*
First Last
Phone*
Mobile
Email*

A copy of the information you provide on this form will be emailed to this email address
Organisation*
Job title
Team*
Professional relationship*

About the person being referred
Name*
First Last
Phone
Mobile
Email
Mark this box if you wish to notify the person that you have requested a referral
- Send notification email
if you mark this box we will send the following message to the person being referred:
"This is to let you know that we have received a referral for advocacy support for you. We will contact the referrer to progress this referral."
Location and contact details
Street*
City or town*
Postcode*
Care home, ward or unit

If the person is currently in a care home, hospital ward or secure unit, please specify. Otherwise please leave blank
Preferred contact method

Demographic information
Birthdate*
DD slash MM slash YYYY
Gender*
Gender description*

If you selected "other/prefer to self-describe" above, please provide further information here
Ethnic group*
Sexual orientation*
Sexual orientation description*

If you selected "other/prefer to self-describe" above, please provide further information here
Religion*
Religion description*

If you selected "other/prefer to self-describe" above, please provide further information here
Disability*
Disability description*

If you selected "other" above, please provide further information here

Communication
Language spoken*
Communication support required or used
Communication professional required
Communication observations
What do we need to know about their communication needs?
Preferred information format

Additional information
Risks
Please tell us anything we need to know to keep the person being referred and us safe.
Additional information
Please tell us anything else you think will help with this referral
Permission for us to use this data*
- Please mark this box if you understand that by submitting this personal information you are consenting to The Advocacy Project holding and using it in accordance with our privacy policy.
Please note we may share this referral information with one of our partner organisations if they are delivering the service you need.
Comments
This field is for validation purposes and should be left unchanged.

Nature of Care Act process