Matrix Advocacy

Personal details:

Client's name:    Date of birth:   Gender:

Current location at present (incl. postcode & telephone):

Usual address (e.g. residence, if different from the above):

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 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 decision that needs to be made? (Reason for referral)

Please choose Serious medical treatment Accommodation Move Safeguarding Adults Care Review

Has there been a Capacity Assessment regarding this decision?

Please choose Yes No

NB: MCA05 states that we must assume capacity unless someone has been assessed as lacking capacity to make a particular decision at a particular time. We may request a copy of this assessment.

What is the reason or cause for the person's lack of capacity?

Please choose Unconscious Autism Spectrum Condition Mental Health Problems Serious Physical Illness Acquired Brain Injury Dementia Learning Disability Cognitive Impairment Combination Other - please specify below

Please give details of the decision and any significant dates:

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):

Referrer's contact details:

Name:                      Job title:

Address (incl. postcode):

Tel:     Mobile:      Email: