Dorset Online Referrals

This form is for referrals for General Advocacy

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Contact Email *

Are you asking for an advocate for yourself? *

• Yes
• No

If yes, how did you hear of SWAN? *

If you are asking for an advocate for someone else, have they given their consent? *

• Yes
• No

May we contact the client directly? *

• Yes
• No

If no, who should we contact? *

Referrer Information

Referrer Full Name *

Job Title *

Referrer Phone *

Referrer Email *

Relationship to Client *

Referrer Address *

Client Information

(the client is the adult needing an advocate)

Client Full Name *

Client DOB *

Address at Referral *

Phone Number at Point of Referral *

Home Address

(if different from referral address)

Home phone number

(if different from referral phone number)

Client Email *

Does the client have any special needs we should consider when visiting, or arranging to meet with them? *

(e.g. do they have difficulty in communicating verbally/in writing?)

Are there any risks that we should be aware of when visiting or arranging to meet with the client? *

Please indicate which are of advocacy is required:

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Pan-Dorset: general issues advocacy for individuals receiving a commissioned service from the local authority

• Older people aged 50+
• Learning disabilities
• Physical disabilities
• Long-term conditions
• Drug/alcohol
• Autism
• Young people in transition

Parents with learning disabilities

• Referral from Adults services
• Referral from Childrens services

Please state briefly what you feel the advocacy issue to be:

Do you/the client have a commissioned POC and/or be under a CMHT for MH referrals? *

• Yes
• No

To receive this service, the client must have a commissioned Package of Care and/or be under a Community Mental Health Team for mental health referrals.

Unfortunately we are unable to continue your referral without a POC or CMHT in place.

Please contact us directly on 03333447928 or dorset@swanadvocacy.org.uk if you wish to discuss this further.

Consent

In making this referral, I declare that: I wish to request advocacy support from South West Advocacy Network (SWAN). I understand that client information supplied on this form will be stored safely on SWAN’s system. I confirm that I am either a self-referring client or I have consent from the client to make the referral, or I have the authority to make the referral for the client. *

• I consent

By requesting advocacy support, you give consent to SWAN sharing information where necessary for the purpose of providing this service. All data held by SWAN is held in accordance with the current UK General Data Protection Regulations legislation.

Submit

SWAN IMCA service represents and supports individuals across Dorset, Bournemouth, Christchurch and Poole who meet all the following criteria:

The person referred has no appropriate family or friends to represent them and the referrer believes that they lack the capacity, decision specific, concerning:

a. Serious medical treatment OR
b. Long term accommodation moves (more than 28 days in hospital/8 weeks in a care home) OR
c. Care reviews OR
d. Safeguarding measures within an adult protection case even where there are family or friends to consult with.

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Contact Email *

Referrer Information

Title *TitleDrMrMrsMissMsOther

Referrer Full Name *

Job Title *

Organisation *

Referrer Phone *

Referrer Email *

Referrer Address *

Client Information

(the client is the adult needing an advocate)

Client Full Name *

Client DOB *

Address at Referral *

Phone Number at Point of Referral *

Home Address

(if different from referral address)

Home phone number

(if different from referral phone number)

Preferred Communication Method

(please indicate and give brief details as appropriate)

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Preferred Communication Method *

• English
• British Sign Language
• Other spoken language
• No obvious communication
• Pictures/symbols/makaton
• Gestures/vocalisations/facial expressions
• Other

If other, please specify: *

Who is the IMCA decision maker?

The decision maker is the individual within either the local authority or the NHS body who has the responsibility for making the decision on issues of change of accommodation or serious medical treatment on behalf of the client who has been assessed as lacking capacity on either issue. A third party can make the referral if they have the permission of the decision maker to do so.

Are you, as the referrer, also the decision maker? *

• Yes
• No

Decision-Maker Details

(Required for change of accommodation or serious medical treatment)

Decision Maker Title *TitleDrMrMrsMissMsOther

Decision Maker Name *

Decision Maker Job Title *

Decision Maker Organisation *

Decision Maker Address *

Decision Maker Phone *

Decision Maker Email *

Decision to be Made *

• Serious Medical Treatment
• Change in Accommodation

Capacity Assessment

We can only accept an IMCA referral when a recent, decision specific, capacity assessment has taken place AND A COPY IS RETURNED WITH THIS REFERRAL FORM. In exceptional circumstances SWAN may consider older evidence if the rationale is clearly identified.

Has this client been formally assessed to lack capacity? *

• Yes
• No

Refusal of Referral

Unfortunately we are unable to accept an IMCA referral without a formal capacity assessment in place. Please call our main line on 03333447928 or email us at dorset@swanadvocacy.org.uk for more information.

Please upload capacity assessment *

Click or drag a file to this area to upload.

A decision specific capacity assessment was completed on: *

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Name of Assessor *

Job Title *

Please provide any important deadlines or meeting dates:

Are there any risks that we should be aware of when visiting or arranging to meet with the client? *

Does the client have family or close friends appropriate to consult? *

• Yes
• No

If there are family or friends, why is an IMCA needed? *

Please provide names and contact details of anyone else who can help form a true picture of the client’s wishes and feelings:

Consent

In making this referral, I declare that: I wish to request advocacy support from South West Advocacy Network (SWAN). I understand that client information supplied on this form will be stored safely on SWAN’s system. I confirm that I am either a self-referring client or I have consent from the client to make the referral, or I have the authority to make the referral for the client. *

• I consent

By requesting advocacy support, you give consent to SWAN sharing information where necessary for the purpose of providing this service. All data held by SWAN is held in accordance with the current UK General Data Protection Regulations legislation.

Submit

Criteria:

The client must be a resident in Dorset, Bournemouth, Christchurch or Poole at the time of the referral. We can only accept a referral if the person needing an advocate has given their consent. If the referrer believes they do not have the capacity to consent, they must give brief details on the ‘additional information’ section of the referral form.
The client must:

• have been assessed as having substantial difficulty in being involved in the process and
• not have anyone other than paid staff willing or appropriate to support them

A referral may also be made where there is disagreement between the local authority and the appropriate person whose role it would be to facilitate the individual’s involvement, and there is agreement that the involvement of an independent advocate would be beneficial to the individual.

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Contact Email *

Has this client been formally assessed as having a substantial difficulty as defined in the Care Act 2014? *

• Yes
• No

Please contact us

Please call us on 03333 447928 or email dorset@swanadvocacy.org.uk to discuss your referral further

Name of Referrer *

Job Title *

Does the client have family or close friends appropriate to support them? *

• Yes
• No

If there are family or friends, why is an advocate needed? *

Care Act Guidance state advocacy is needed where there is no other appropriate adult to help them.

Support required for:

(please indicate as appropriate)

An independent advocate must be appointed to support and represent the person for the purpose of assisting their involvement if these two conditions are met and if the individual is required to take part in one or more of the following processes: *

• Needs Assessment
• Carers’ Assessment
• Preparation/Review of a Care and Support Plan or Support Plan
• Childs Needs Assessment
• Childs Carers Assessment
• Young Carers Assessment
• Appeal against a local authority decision under Part 1 of the Care Act

Client Information

(the client is the adult needing an advocate)

Client Full Name *

Client DOB *

Address at Referral *

Phone Number at Point of Referral *

Home Address

(if different from referral address)

Home phone number

(if different from referral phone number)

Preferred communication method *

• English
• Other spoken language
• Pictures/symbols/Makaton
• British Sign Language
• No obvious communication
• Gestures/vocalisations/facial expressions
• Other

(please indicate and give brief details as appropriate)

If other, please specify *

Is the client a carer? *

• Yes
• No

Name of Local Authority Practitioner involved with this issue

Full Name *

Job Title *

Organisation *

Team *

Phone *

Email *

Address *

Are you referring from the NHS Continuing Healthcare (CHC) Team? *

• Yes
• No

Are you, the referrer, the Local Practitioner involved? *

• Yes
• No

Referrer Information

(if different to Local Authority Practitioner)

Referrer Full Name *

Job Title *

Referrer Phone *

Referrer Email *

Referrer Address *

Please state the advocacy need *

Risk information *

e.g. pets at the home, substance/tobacco use, behavioural issues, neighbourhood concerns, risk of self harm/suicide, other members of the household

Please detail any important deadlines or meeting dates

Consent

In making this referral, I declare that: I wish to request advocacy support from South West Advocacy Network (SWAN). I understand that client information supplied on this form will be stored safely on SWAN’s system. I confirm that I am either a self-referring client or I have consent from the client to make the referral, or I have the authority to make the referral for the client. *

• I consent

By requesting advocacy support, you give consent to SWAN sharing information where necessary for the purpose of providing this service. All data held by SWAN is held in accordance with the current UK General Data Protection Regulations legislation.

Submit

NB: SWAN can only accept a referral if the person needing an advocate has given their consent. If you believe they do not have the capacity to consent, please give brief details on the ‘additional information’ section of this form.

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Contact Email *

Are you asking for an advocate for yourself? *

• Yes
• No

If yes, how did you hear of SWAN? *

If you are asking for an advocate for someone else, have they given their consent? *

• Yes
• No

May we contact the client directly? *

• Yes
• No

If no, who should we contact? *

Referrer Information

Referrer Full Name *

Job Title *

Referrer Phone *

Referrer Email *

Relationship to Client *

Referrer Address *

Are you referring from the NHS Continuing Healthcare (CHC) Team? *

• Yes
• No

Client Information

(the client is the adult needing an advocate)

Client Full Name *

Client DOB *

Address at Referral *

Phone Number at Point of Referral *

Home Address

(if different from referral address)

Home phone number

(if different from referral phone number)

Client Email *

Is the client:

• Detained under MHA Sec 2__/Sec 3__
• Subject to a CTO
• Subject to a Guardianship order
• Subject to a restricted conditional discharge
• Considered for Section 57 treatment
• Under 18 & considered for ECT
• Under 18 and considered for sec 58A

(please indicate eligibility)

Does the client have any special needs we should consider when visiting, or arranging to meet with them? *

(e.g. do they have difficulty in communicating verbally/in writing?)

Are there any risks that we should be aware of when visiting or arranging to meet with the client? *

Please state any pertinent information about the client *

Any information will be shared with the client unless the client is deemed not to have the capacity to instruct.

Consent

In making this referral, I declare that: I wish to request advocacy support from South West Advocacy Network (SWAN). I understand that client information supplied on this form will be stored safely on SWAN’s system. I confirm that I am either a self-referring client or I have consent from the client to make the referral, or I have the authority to make the referral for the client. *

• I consent

By requesting advocacy support, you give consent to SWAN sharing information where necessary for the purpose of providing this service. All data held by SWAN is held in accordance with the current UK General Data Protection Regulations legislation.

Submit

This form is for referrals for those eligible for Carers Advocacy
Carers Advocacy is for carers of individuals with health and social care needs living within the pan-Dorset area who are eligible for Care Act Advocacy Support.
Advocates can support and represent carers in:

• An assessment of care and support

• Care and support planning

• Review of care and support

• General, issue-based advocacy

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Contact Email *

Are you asking for an advocate for yourself? *

• Yes
• No

If yes, how did you hear of SWAN? *

If you are asking for an advocate for someone else, have they given their consent? *

• Yes
• No

May we contact the client directly? *

• Yes
• No

If no, who should we contact? *

Referrer Information

Referrer Full Name *

Job Title *

Referrer Phone *

Referrer Email *

Relationship to Client *

Referrer Address *

Are you referring from the NHS Continuing Healthcare (CHC) Team? *

• Yes
• No

Carer Information

(the carer is the adult needing an advocate and is aged over 16 years)

Carer Full Name *

Carer DOB *

Address at Referral *

Phone Number at Point of Referral *

Home Address

(if different from referral address)

Home phone number

(if different from referral phone number)

Carer Email *

Does the client have any special needs we should consider when visiting, or arranging to meet with them? *

(e.g. do they have difficulty in communicating verbally/in writing?)

During the advocacy process will you/carer have difficulty communicating views and feelings/have difficulty retaining information/understanding information/weighing up the information? *

Are there any risks that we should be aware of when visiting or arranging to meet with the client? *

Please indicate which area of Carers Advocacy is required: *

• Assessment
• Planning
• Review
• General, issue-based advocacy

Please state briefly what you feel the advocacy issue to be: *

Consent

In making this referral, I declare that: I wish to request advocacy support from South West Advocacy Network (SWAN). I understand that client information supplied on this form will be stored safely on SWAN’s system. I confirm that I am either a self-referring client or I have consent from the client to make the referral, or I have the authority to make the referral for the client. *

• I consent

By requesting advocacy support, you give consent to SWAN sharing information where necessary for the purpose of providing this service. All data held by SWAN is held in accordance with the current UK General Data Protection Regulations legislation.

Submit

PLEASE NOTE: IT IS THE RESPONSIBILITY OF THE REFERRER TO ENSURE THAT FUNDING FOR THE SOLICITORS FEES HAS BEEN ARRANGED.

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Contact Email *

Referrer Information

Referrer Full Name *

Job Title *

Referrer Address *

Client Information

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Client Full Name *

Known As:

Client DOB *

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Address at Referral *

Phone Number at Point of Referral *

Contact Name at Referral Address *

Home Address

(if different from referral address)

Home phone number

(if different from referral phone number)

Contact Name at Home Address

Preferred Communication Method

(please indicate and give brief details as appropriate)

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Preferred Communication Method *

• English
• Other spoken language
• Pictures/symbols
• Makaton/British Sign Language
• Gestures/vocalisations/facial expressions
• No obvious communication
• Other

If other, please specify: *

Nature of Illness or Impairment

(please indicate and give brief details as appropriate)

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Nature of illness or impairment *

• Learning disability
• Mental illness
• Dementia
• Serious physical illness
• Acquired brain injury
• Unconscious state
• Other

If other, please specify: *

Details of Relevant Professionals

Details of Relevant Professionals

Name

Name 2

Name 3

Name 4

Address

Address 2

Address 3

Address 4

Connection to Client

Connection to Client 2

Connection to Client 3

Connection to Client 4

For a S16 referral please confirm how the solicitor’s fees will be paid? *

• Privately – The client will be paying the Solicitor’s fees with their own funds and this has been agreed.
• Legal Aid – The client is eligible for Legal Aid Funding and this has been confirmed by the Local Authority/NHS Dorset (ICB).
• Local Authority/NHS Dorset (ICB) – The Local Authority or NHS Dorset (ICB) has agreed to pay the solicitors fees up to and including the first hearing.

Without one of the above funding streams being confirmed, we are not able to provide a Litigation Friend.

Capacity Assessment

A decision specific capacity assessment was completed on: *

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Name of Assessor *

Job Title *

Please provide any important deadlines or meeting dates:

Please state briefly the advocacy need: *

Consent

In making this referral, I declare that: I wish to request advocacy support from South West Advocacy Network (SWAN). I understand that client information supplied on this form will be stored safely on SWAN’s system. I confirm that I am either a self-referring client or I have consent from the client to make the referral, or I have the authority to make the referral for the client. *

• I consent

By requesting advocacy support, you give consent to SWAN sharing information where necessary for the purpose of providing this service. All data held by SWAN is held in accordance with the current UK General Data Protection Regulations legislation.

Submit

This referral form is for Parents with Learning Disabilities:

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Contact Email *

Are you asking for an advocate for yourself? *

• Yes
• No

If yes, how did you hear of SWAN? *

If you are asking for an advocate for someone else, have they given their consent? *

• Yes
• No

May we contact the client directly? *

• Yes
• No

If no, who should we contact? *

Referrer Information

Referrer Full Name *

Job Title *

Referrer Phone *

Referrer Email *

Relationship to Client *

Referrer Address *

Client Information

(the client is the adult needing an advocate)

Client Full Name *

Client DOB *

Address at Referral *

Phone Number at Point of Referral *

Home Address

(if different from referral address)

Home phone number

(if different from referral phone number)

Client Email *

Does the client have any special needs we should consider when visiting, or arranging to meet with them? *

(e.g. do they have difficulty in communicating verbally/in writing?)

Are there any risks that we should be aware of when visiting or arranging to meet with the client? *

Please indicate which area of LA the Parents with Learning Needs referral is from:

• Referral from Adults services
• Referral from Childrens services

Please state briefly what you feel the advocacy issue to be:

Consent

In making this referral, I declare that: I wish to request advocacy support from South West Advocacy Network (SWAN). I understand that client information supplied on this form will be stored safely on SWAN’s system. I confirm that I am either a self-referring client or I have consent from the client to make the referral, or I have the authority to make the referral for the client. *

• I consent

By requesting advocacy support, you give consent to SWAN sharing information where necessary for the purpose of providing this service. All data held by SWAN is held in accordance with the current UK General Data Protection Regulations legislation.

Submit