Somerset Online Referrals

SWAN supports clients in need of generic advocacy, who are over 18 and resident in Somerset. SWAN can only accept a referral if the person needing an advocate has given their consent.

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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? *

Is the client:

In receipt of, or disputing access to, secondary services? *

• Yes
• No

In receipt of, or disputing access to, Disability Living Allowance/Personal Independence Payment? *

• Yes
• No

Providing unpaid care for an adult in receipt of the above services? *

• Yes
• No

Please tick the primary vulnerability of the person being referred: *

• Older people aged 60+
• Learning Disabilities
• Physical Impairment
• Acquired Brain Injury
• Autism Spectrum Disorder
• Mental Health Needs
• Dementia
• Carer
• Sensory Impairment
• Other

If other, please specify *

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

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

Are there any deadlines or important 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 *

Team *TeamAdult Social Care – Bridgwater & North SedgemoorAdult Social Care – Taunton & West SomersetAdult Social Care – MendipAdult Social Care – South SomersetMental Health Social Care – WestMental Health Social Care – EastMental health Social Care – InpatientsLearning Disability – WestLearning Disability – EastPreparing for Adulthood (Transitions)Health Interface Service (Acutes)Intermediate Care Service (Community Hospitals and Pathways)Adults Safeguarding TeamSomerset Foundation TrustOther

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 *

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Please tick any criteria which apply to the client:

• Learning Disability
• Physical Disability
• Mental Ill Health
• Sensory Impairment
• Aging (Over 60)
• Dementia
• Acquired Brain Injury
• Autistic Spectrum Disorder

Please include details of 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

SWAN IMCA service represents and supports individuals across Somerset 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

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Contact Email *

Referrer Information

Title *TitleDrMrMrsMissMsOther

Referrer Full Name *

Job Title *

Team *TeamAdult Social Care – Bridgwater & North SedgemoorAdult Social Care – Taunton & West SomersetAdult Social Care – MendipAdult Social Care – South SomersetMental Health Social Care – WestMental Health Social Care – EastMental health Social Care – InpatientsLearning Disability – WestLearning Disability – EastPreparing for Adulthood (Transitions)Health Interface Service (Acutes)Intermediate Care Service (Community Hospitals and Pathways)Somerset Foundation TrustAdults Safeguarding TeamOther

Organisation *

Referrer Phone *

Referrer Email *

Referrer Address *

Client Information

Client Full Name *

Client DOB *

Address at Referral *

(if hospital, please include ward name)

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
• 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)

Layout (copy)

Nature of illness or impairment *

• Learning Disability
• Physical Disability
• Mental Ill Health
• Sensory Impairment
• Aging (Over 60)
• Dementia
• Acquired Brain Injury
• Autistic Spectrum Disorder
• 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 *

Person to contact to arrange meeting with client: *

Decision to be made

Decision to be Made *

• Serious Medical Treatment
• Change of Accommodation
• Care Review for Recent Placement

Please provide details as relevant:

Has a Local Authority Section 42 enquiry been opened? *

• Yes
• No

Refusal of Referral

Unfortunately we are unable to accept an IMCA referral without a local authority Section 42 in place. Please call our main line on 03333447928 or email us at somerset@swanadvocacy.org.uk for more information.

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 portsmouth@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 Somerset 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.

Please enable JavaScript in your browser to complete this form.

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 *

Team *TeamAdult Social Care – Bridgwater & North SedgemoorAdult Social Care – Taunton & West SomersetAdult Social Care – MendipAdult Social Care – South SomersetMental Health Social Care – WestMental Health Social Care – EastMental health Social Care – InpatientsLearning Disability – WestLearning Disability – EastPreparing for Adulthood (Transitions)Health Interface Service (Acutes)Intermediate Care Service (Community Hospitals and Pathways)Adults Safeguarding TeamSomerset Foundation TrustOther

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 *

Layout

Please tick any criteria which apply to the client:

• Learning Disability
• Physical Disability
• Mental Ill Health
• Sensory Impairment
• Aging (Over 60)
• Dementia
• Acquired Brain Injury
• Autistic Spectrum Disorder

Please highlight purpose of referral:

• Care Review
• Care Planning/Preperation
• Safeguarding

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