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Telephone: 03333 447928 Email: reception@swanadvocacy.org.uk

East Sussex Online Referrals

To complete an online referral, please see tabs below:

Adults IMHA Referral

To check eligibility for a referral into the service for an IMHA please click here

Please enable JavaScript in your browser to complete this form.

Contact Email *

Are you asking for an advocate for yourself? *

Have they given their consent? *

May we contact the client directly? *

Who should we contact? *

Referrer Details

Full Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Job Title *

Team *

Client Details

Full Name *

Preferred Name

Pronouns

(if known)

Address at Point of Referral *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if hospital, please include ward name)

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if different)

Phone *

Date of Birth *

Sexual Orientation *

Ethnicity *

Religion *

Gender *

Gender same as assigned at birth? *

Yes
No
Prefer not to say

Any disabilities?

Chronic or long-term conditions
Chronic or long-term pain
Hearing
Learning disability
Memory
Neurodivergent
Mental illness
Mobility
Neurological condition
Speech or language
Stamina, breathing or fatigue
Vision
Other
Prefer not to say

Please tick all that apply

Is the client a carer? *

Yes
No
Prefer not to say

Has the client ever served in the Armed Forces? *

Yes
No
Prefer not to say

Is the client: *

Detained under MHA Sec 2
Detained under MHA Sec 3
Subject to CTO (Community treatment order)
Subject to a Guardianship order
Subject to a restricted conditional discharge
Considered for Section 57 treatment

Please indicate eligibility

Additional information or comments relating to any of the above:

Any vulnerabilities and/or risks we should consider when visiting, contacting or arranging to meet with the client?

(e.g. do they have difficulty in communicating verbally/in writing, mental health issues, substance use etc.)

Any communication needs?

Any key information and/or key dates?

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 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.

Adults ICAA Referral

To check eligibility for a referral into the service for an ICAA please click here

Please enable JavaScript in your browser to complete this form.

Contact Email *

Local Authority Practitioner involved with this issue

Full Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Job Title *

Team *

Locality *

Phone *

Email *

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

Referrer Details

Full Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone *

Email *

Job Title *

Team *

Client Details

Full Name *

Preferred Name

Pronouns

(if known)

Address at Point of Referral *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if hospital, please include ward name)

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if different)

Phone *

Date of Birth *

Sexual Orientation *

Ethnicity *

Religion *

Gender *

Gender same as assigned at birth? *

Yes
No
Prefer not to say

Any disabilities?

Chronic or long-term conditions
Chronic or long-term pain
Hearing
Learning disability
Memory
Neurodivergent
Mental illness
Mobility
Neurological condition
Speech or language
Stamina, breathing or fatigue
Vision
Other
Prefer not to say

Please tick all that apply

Is the client a carer? *

Yes
No
Prefer not to say

Has the client ever served in the Armed Forces? *

Yes
No
Prefer not to say

Best way to contact client *

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

Full Name of Assessor *

Date of assessment *

Job Title *

Issue for which they were assessed *

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

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

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

Referral Details

Support required for: 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 of a Care & Support or Support Plan
Review of Care & Support or Support Plan
Safeguarding Section 42 enquiry or review*
Appeal against Local Authority decision under part one of the Care Act

*We are unable to provide advocacy unless a Section 42 enquiry has been opened.

Additional information or comments relating to any of the above

Any vulnerabilities and/or risks we should consider when visiting, contacting or arranging to meet with them?

(e.g. do they have difficulty in communicating verbally/in writing, mental health issues, substance use etc.)

Any communication needs?

Any key dates?

I consent

Adults Community Referral

SWAN supports clients in need of community advocacy who meet the eligibility criteria within East Sussex.

We accept self-referrals or referrals made from third parties

Please enable JavaScript in your browser to complete this form.

Contact Email *

Are you asking for an advocate for yourself? *

Have they given their consent? *

May we contact the client directly? *

Who should we contact? *

Referrer Details

Full Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Job Title *

Team *

Client Details

Full Name *

Preferred Name

Pronouns

(if known)

Address at Point of Referral *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if hospital, please include ward name)

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if different)

Phone *

Date of Birth *

Sexual Orientation *

Ethnicity *

Religion *

Gender *

Gender same as assigned at birth? *

Yes
No
Prefer not to say

Any disabilities?

Chronic or long-term conditions
Chronic or long-term pain
Hearing
Learning disability
Memory
Neurodivergent
Mental illness
Mobility
Neurological condition
Speech or language
Stamina, breathing or fatigue
Vision
Other
Prefer not to say

Please tick all that apply

Is the client a carer? *

Yes
No
Prefer not to say

Has the client ever served in the Armed Forces? *

Yes
No
Prefer not to say

Any communication needs?

This service is available to residents of East Sussex who are funded by East Sussex County Council and: *

Aged 65 or over
Between 18 and 65 with physical disabilities
Between 18 and 65 with sensory impairments
Over the age of 18 with a learning disability
Over the age of 18 with mental health issues
A carer of someone eligible under the above categories

Advocacy Need *

To make a complaint about Adult Social Care.
For support around direct payment issues
Need support through safeguarding or best interest process
Need to raise safeguarding
Support around the financial appeal process
Advocacy support with Occupational Therapy issues
Complaints to the Local Government and Social Care Ombudsman
Accessing services re mental health care and treatment
Challenging decisions for Adult Social Care services, including personal budgets, client contributions and placement decisions.
Supporting Carers to apply for Carers assessments
Support to request or to attend assessment and review processes for care packages and financial assessments for care.

Any vulnerabilities and/or risks we should consider when visiting, contacting or arranging to meet with them?

(e.g. do they have difficulty in communicating verbally/in writing, mental health issues, substance use etc.)

Any key information and/or key dates?

I consent

Children & Young People IMHA Referral

To check eligibility for a referral into the service for an IMHA please click here

Please enable JavaScript in your browser to complete this form.

Contact Email *

Are you asking for an advocate for yourself? *

Have they given their consent? *

May we contact the client directly? *

Who should we contact? *

Referrer Details

Full Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Job Title *

Team *

Children/Young Person's Details

Full Name *

Preferred Name

Pronouns

(if known)

Address at Point of Referral *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if hospital, please include ward name)

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if different)

Phone *

Date of Birth *

Sexual Orientation *

Ethnicity *

Religion *

Gender *

Gender same as assigned at birth? *

Yes
No
Prefer not to say

Any disabilities?

Chronic or long-term conditions
Chronic or long-term pain
Hearing
Learning disability
Memory
Neurodivergent
Mental illness
Mobility
Neurological condition
Speech or language
Stamina, breathing or fatigue
Vision
Other
Prefer not to say

Please tick all that apply

Child's legal status *

Date child became looked after

Resident Local Authority *

If other, please state Local Authority *

Does the child have a protection plan? *

Support required for *

Detained under MHA Sec 2
Detained under MHA Sec 3
A voluntary patient under consideration for ECT
Child subject to a Community Treatment Order (CTO)
Child subject to Sections 27, 47, 48 or 49 (Crime Committed)
Other

Please indicate eligibility

If other, please specify *

Additional information or comments relating to any of the above:

Any vulnerabilities and/or risks we should consider when visiting, contacting or arranging to meet with the client?

(e.g. do they have difficulty in communicating verbally/in writing, mental health issues, substance use etc.)

Any communication needs?

Any key information and/or key dates?

Child/Young Person's Parent/Primary Details

Is the parent/primary carer aware of this referral? *

Full Name *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Child/Young Person's Social Worker Details

Full Name *

Job Title *

Team *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

School/College Details

Full Name *

Job Title *

Team *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

I consent

Children & Young People IMCA Rule 1.2 Referral

Please note: the current care and support plan and draft COP11 (if available) should be submitted with this referral.

Please enable JavaScript in your browser to complete this form.

Contact Email *

Referrer Details

Full Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Job Title *

Team *

Children/Young Person's Details

Full Name *

Preferred Name

Pronouns

(if known)

Address at Point of Referral *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if hospital, please include ward name)

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if different)

Phone *

Date of Birth *

Sexual Orientation *

Ethnicity *

Religion *

Gender *

Gender same as assigned at birth? *

Yes
No
Prefer not to say

Any disabilities?

Chronic or long-term conditions
Chronic or long-term pain
Hearing
Learning disability
Memory
Neurodivergent
Mental illness
Mobility
Neurological condition
Speech or language
Stamina, breathing or fatigue
Vision
Other
Prefer not to say

Please tick all that apply

Child's legal status *

Date child became looked after

Resident Local Authority *

If other, please state Local Authority *

Does the child have a protection plan? *

Any communication needs?

Details of Relevant Professionals

Name

Name 2

Name 3

Name 4

Email 2

Email 3

Email 4

Connection to child/young person

Connection 2

Connection 3

Connection 4

Capacity Assessment

Has the child been formally assessed to lack capacity? *

A decision specific capacity assessment was completed on *

Name of Assessor *

Job Title *

Any key information and/or key dates?

Please briefly state the advocacy requirement *

Child/Young Person's Parent/Primary Details

Is the parent/primary carer aware of this referral? *

Full Name *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Child/Young Person's Social Worker Details

Full Name *

Job Title *

Team *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please upload current Care and Support Plan and draft COP11 (if available)

Click or drag files to this area to upload. You can upload up to 2 files.

If you have issues uploading the documents, please submit this referral without the documents and email them seperately to eastsussex@swanadvocacy.org.uk

I consent

Children & Young People Specialist Referral

SWAN’s Specialist CYP Advocacy Service ONLY accepts referrals from East Sussex Children’s Disability Service

Please enable JavaScript in your browser to complete this form.

Contact Email *

Are you asking for an advocate for yourself? *

Have they given their consent? *

May we contact the client directly? *

Who should we contact? *

Referrer Details

Full Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Job Title *

Team *

Children/Young Person's Details

Full Name *

Preferred Name

Pronouns

(if known)

Address at Point of Referral *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if hospital, please include ward name)

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

(if different)

Phone *

Date of Birth *

Sexual Orientation *

Ethnicity *

Religion *

Gender *

Gender same as assigned at birth? *

Yes
No
Prefer not to say

Any disabilities?

Chronic or long-term conditions
Chronic or long-term pain
Hearing
Learning disability
Memory
Neurodivergent
Mental illness
Mobility
Neurological condition
Speech or language
Stamina, breathing or fatigue
Vision
Other
Prefer not to say

Please tick all that apply

Child's legal status *

Date child became looked after

Resident Local Authority *

If other, please state Local Authority *

Does the child have a protection plan? *

Support required for *

Initial Child Protection Conference
Review CP Conference
Core Group (If YP attending)
Family Group Conference
Care Leaver/transition
LAC Review
Contact
Complaint against Children’s Services
Other

Please indicate eligibility

If other, please specify *

Additional information or comments relating to any of the above:

Any vulnerabilities and/or risks we should consider when visiting, contacting or arranging to meet with the client?

(e.g. do they have difficulty in communicating verbally/in writing, mental health issues, substance use etc.)

Any communication needs?

Any key information and/or key dates?

Child/Young Person's Parent/Primary Details

Is the parent/primary carer aware of this referral? *

Full Name *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Child/Young Person's Social Worker Details

Full Name *

Job Title *

Team *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

School/College Details

Full Name *

Job Title *

Team *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

I consent

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Telephone: 03333 447928 Email: reception@swanadvocacy.org.uk

East Sussex Online Referrals

To complete an online referral, please see tabs below:

Adults IMHA Referral

Referrer Details

Client Details

Adults ICAA Referral

Local Authority Practitioner involved with this issue

Referrer Details

Client Details

Referral Details

Adults Community Referral

Referrer Details

Client Details

Children & Young People IMHA Referral

Referrer Details

Children/Young Person's Details

Child/Young Person's Parent/Primary Details

Child/Young Person's Social Worker Details

School/College Details

Children & Young People IMCA Rule 1.2 Referral

Referrer Details

Children/Young Person's Details

Details of Relevant Professionals

Capacity Assessment

Child/Young Person's Parent/Primary Details

Child/Young Person's Social Worker Details

Children & Young People Specialist Referral

Referrer Details

Children/Young Person's Details

Child/Young Person's Parent/Primary Details

Child/Young Person's Social Worker Details

School/College Details

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