Personal details:

Client's name:    Date of birth:   Gender:

Address at present (incl. postcode & telephone):

Funding authority:

What is the person's ethnic background? (to the best of your knowledge):

White Mixed Black or Black British Asian or Asian British Chinese or other Unknown Please choose

What is the understanding of the person's capacity to make this decision?

Please choose Lacks capacity in the short term Lacks capacity for the forseeable future Lacks capacity for an unspecified period

On what basis was the decision about the person's capacity made?

Please choose Decision maker's judgement Assessment by other professional Other (please specify below)

What is the person's primary communication method?

Please choose Spoken English Other spoken language - please specify below) Gestures/facial expressions/vocalisations British Sign Language Pictures/symbols/Makaton No obvious communication Other - please specify below

What is the reason for referral? (issue)

Please choose Serious medical treatment Move to accommodation provided by an NHS body Move to accommodation provided by Local Authority Adult Protection Review of Care

Significant dates:

When does the decision need to be made by:

Please give details of any impending meetings or deadlines:

Referrer's contact details:

Name:                      Job title:

Address (incl. postcode):

Tel:     Mobile:      Email:

Decision maker's contact details (leave blank if same as referrer)

Name:                        Job title:

Address (incl. postcode):

Tel:     Mobile:        Email:

Person to contact to arrange meeting with client:

Name:                       Job title:

Address (incl. postcode):

Tel:     Mobile:        Email:

Any other specific needs or relevant issues? (communication methods, access issues, etc):

Are there any family members, (non-paid) carers, friends, etc to consult?:

Please choose Yes No Uncertain

if you answered 'Yes' to the above, why is an IMCA needed? (e.g. why have they not been consulted, or why do you think they are inappropriate to consult?):

Names and contact details of anyone who may be able to indicate the person who lacks capacity's wishes (e.g. Care Manager, Doctor, manager of home, care staff, nurses or other significant person):