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People First Advocacy Referral

People First Advocacy Referral

I'm making a referral for: 

Please select an option from the list

What advocacy support are you seeking: 

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Where is the referral taking place? Please select an option. 
We do not offer this service in Cumbria, please visit N-Compass
What area are you in? Please choose an option.  
We do not offer this service outside of Carlisle and Eden, please visit your local Citizen's Advice Bureau.

Support

What IMCA support do you require? 
Which Local Authority process do you require support with? 

Their contact details

Please select an option from the menu

Please enter their first name in the field

Please enter their surname in the field

Gender 

Please select their gender

Please select an option from the menu

Please enter their email address in the field

Please enter their contact number in the field

Please enter their alternative contact number in the field if relevant

Please enter their address in the field

Please enter their postcode in the field

Please choose from the following

Their preferred contact method

Please select an option from the list

Further details about the person you are referring

How do they communicate? 

Please select an option from the list

Please enter their language in the field

Please enter their communication method in the field

Please select an option from the menu

Select one or more disabilities from the following: 

Please select an option from the list

Please select an option from the menu

Please enter their nationality in the field

Please enter any risks in the field

Please select an option from the menu

Please enter the reason(s) in the field

Your contact details

Please select an option from the menu

Please enter your first name in the field

Please enter your surname in the field

Gender 

Please select your gender

Please enter your date of birth from the options below

Please enter your email address in the field

Please enter your telephone number in the field

Please enter your alternative telephone number in the field if relevant

Please enter your address in the field

Please enter your postcode in the field

Please choose from the following

Preferred contact method

Please select an option from the list

Further details about you

How do you communicate? 

Please select an option from the list

Please enter the language(s) in the field

Please specify your communication method in the field

Please select an option from the menu

Select one or more disabilities from the following:

Please select an option from the list

Please select an option from the menu

Please enter your nationality in the field

Please enter any risks in the field

How did you hear about our service?

Please select an option from the list

Please provide your details

Please select an option from the menu

Please enter your first name in the field

Please enter your surname in the field

Please enter your contact number in the field

Please enter your alternative telephone number if relevant

Please enter your email address in the field

Please enter your address in the field

Please enter your postcode in the field

Please enter your relationship with the person in the field

How did you hear about our service? 

Please select an option from the list

Assessment

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Assessment (No)
IMCA is only for people who have been formally assessed as lacking capacity, Please consider whether another advocacy project such as 'Independent Care Act Advocacy' or 'Other Independent Advocacy' may be more appropriate.

Please provide details in the field

Assessment (Yes)

Please enter the date in the fields

Please enter the name of the assessor in the field

Please enter their role into the field

Please enter their contact details in the field

Referral Details

What is the nature of the person's impairment? 

Please select an option from the list

Please specify the impairment in the field

Does this person have any family or friends? 

Please select an option from the list

Please enter the reason in the field

Please enter any specific details in the field

Please enter any risks in the field

The Decision Maker

Please select an option from the menu

Decision Maker Details

Decision Maker Details

Please enter their name in the field

Please enter their organisation name in the field

Please enter their role in the field

Please enter their phone number in the field

Please enter their postal address in the field

Please enter their postcode in the field

Independent Advocacy Referral

At People First we believe that people should be treated equally, fairly and with respect. We know that this doesnt always happen and work to tackle these inequalities by supporting people to be empowered. This service is provided by our Volunteer Citizen Advocacy Project.

Please enter the issue(s) in the field

Please select an option from the menu

Please enter the date(s) and reason(s) in the field

Current Benefits

Select any benefits that apply

Other people

If there are other people involved, please give us their details below. We will not speak to these people without notification first.
People

Independent Care Act Advocacy Referral

The Care Act says your well-being is important and you should be supported to be involved in all decisions about your care and support. You could be entitled to Care Act Advocacy if you find it difficult to access services and you feel you are not being listened to.
Select one as appropriate: 

Please select an option from the list

Please enter what we can help with in the field

Please enter the date(s) and reason(s) in the field

Social workers, professionals or any other people

If there are other people involved, please give us their details below. We will not speak to these people without notification first.
People

Independent Mental Health Advocacy Referral

This form is for people detained under the Mental Health Act or people who are subject to SCT.
Please consider whether another advocacy project may be more appropriate such as 'Independent Care Act Advocacy' or 'Other Independent Advocacy', if you believe these to be more appropriate, please go back and select the desired option.

How we can help you

The Mental Health Act says that if you are subject to some of their sections, you have a right to independent advocacy support. We can help you find the right support.
Select one Section of the Mental Health Act that applies to you: 

Please select an option from the list

Please enter the section in the field

Please enter the start date below

Please enter the end date if known

Please enter what we can help with in the field

Social workers, professionals or any other people

If there are other people involved, please give us their details below. We will not speak to these people without notification first.
People

Independent Children's Advocacy

Please select an option from the menu

Forward My Details To NYAS

Please enter your name in the field

Please enter your contact number in the field

Please enter your email address in the field

Please enter any additional details in the field

About Your NHS Complaint

Which NHS body (or bodies) does the complaint relate to? 

Please select an option from the list

You or the person been referred have a right to make a complaint at any time but to have it investigated by the NHS, in line with their complaints regulations, they advise you to do this within one year of first becoming aware that there was something to complain about.

Please select an option from the menu

Complaints can still be made outside of this time frame however the reasons for not complaining with 1 year will need to be highlighted.

Please enter a description on the complaint in the field

Please enter what you would like to achieve in the field

Local Healthwatch Permissions

Each local authority area has a local Healthwatch. Healthwatch is independent of all health and social care services and is there to listen and gather people’s experiences of using health and care services. Healthwatch uses these experiences to drive improvements. To find out more about your local Healthwatch please visit their website at: healthwatchcumberland.co.uk. healthwatchwestfurn.co.uk. healthwatchmiddlesbrough.co.uk, healthwatchhartlepool.co.uk If you would be happy for us to share your details with your local Healthwatch so they can contact you about your experience, please select one of the following options:
Permissions

Please select an option from the list

Declaration For Data Protection

Because of the Data Protection Act a signature is needed to say that you agree to the Advocacy Hub and the Advocacy Service Provider securely holding and sharing (as appropriate) personal information (including the information on this form), on a computer and in a filing system. It is the policy of the Advocacy Hub and the Advocacy Service Provider that all personal data will be held in accordance with the principles and requirements of Data Protection and other relevant legislation, and that procedures will be put in place to ensure the fair processing of data relating to individuals. The Advocacy Hub and Advocacy Service are confidential service; you can request further information on confidentiality from the Advocacy Hub or the Advocacy Service Provider.

I agree to that the Advocacy Hub and the Advocacy Service Provider can securely hold and put on computer and in a filing system and share (as appropriate), the information on this form.

I would like the Advocate to do this work. The Advocacy Hub and the allocated Advocacy Provider can keep and put on computer and in a filing system and can share (as appropriate), the information on this form provided to do the work. I am providing this information and asking for this referral in the clients best interests.