IMCA - SMT, accom, protective measures

In which London borough is the advocacy required?*
This will be the borough where the person currently is located.
Eligibility for IMCA*
Select the primary reason that you are referring for IMCA
- Long-term accommodation move (more than 28 days in hospital or 8 weeks in residential accommodation)
- Serious medical treatment
- Protective Measures regarding Safeguarding
- Protective Measures regarding Care Review
Have you verified that the person lacks capacity to make the relevant decisions?*
- Lacks capacity for relevant decisions
Selecting this box is required before you can proceed
Is there an appropriate person available to consult?
- No appropriate person to consult
Reason for referral if an appropriate person is available*
If there is an appropriate person available to consult, 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*

Decision maker
If you, the referrer, are also the decision maker, please mark this box
- I am the decision maker
Decision maker name*
First Last
Phone*
Mobile
Email*
Organisation*
Job title
Team

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
Birth date*
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.
Name
This field is for validation purposes and should be left unchanged.

About the issue