Somerset Online Referrals

The Somerset IMCA service represents and supports individuals living in Somerset who meet all the following criteria:

The person referred has no suitable family or friends to consult with, they do not need to hold LPA.

The referrer has conducted a recent, decision specific capacity assessment which shows the client lacks capacity to make one of the following decisions:

a. Serious medical treatment
b. Long term accommodation move (more than 28 days in hospital/8 weeks in a care home)

An IMCA may also be instructed for

c. Care review for a recent placement
d. Adult safeguarding.

If unsure, check out our flowchart

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Somerset IMCA Referral

The person being referred must have all these criteria: resident of Somerset, has been assessed as lacking capacity to make the decision, the decision is change of accommodation or serious medical treatment (can be care review for recent placement or safeguarding) and have no one else suitable to consult. *

• I agree that the person being referred fulfils the criteria.

Please note: financial decisions cannot be supported by an IMCA. A person does not have to hold LPA or deputyship to be suitable, but they must be acting in the client's best interest.

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)

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)

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 *

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

If there are multiple decisions to be made, please complete a referral for each decision.

Please provide details as relevant:

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 somerset@swanadvocacy.org.uk for more information.

Please upload capacity assessment *

Drag & Drop Files, Choose Files to Upload

A decision specific capacity assessment was completed on: *

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

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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Somerset IMHA Referral

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 *

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

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.

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Somerset ICAA Referral

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 *

Ethnic Origin *Ethnic OriginWhite BritishAny other white backgroundBlack/African/CaribbeanMixed or multiple ethnic groupsAsianOther ethnic groupPrefer not to say

Religion or Belief *Religion or BeliefBahiBuddhismChristianityHinduismHumanismIslamJudaismPaganismSikhismOtherPrefer not to sayNot asked

Is their gender the same as assigned at birth? *Gender at birthYesNoPrefer not to say

Gender *GenderWomanManTransgenderGender neutralNon-binaryOtherPrefer not to say

The gender you identify as

Sexual Orientation *Sexual orientationHeterosexualGayBisexualLesbianOtherPrefer not to say

Do you provide care for anyone (e.g. a parent, child, other relative, an elderly person, friend, or neighbour) who has a form of disability (sensory loss, physical, learning disability, mental health problem), long term health issues or terminal illness? *CarerYesNoPrefer not to say

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

To make a Health Complaints referral, please fill out the referral form below:

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Contact Email *

Are you the complainant? *

• Yes
• No

Referrer Details

Full Name *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Phone *

Email *

Job Title *

Complainant 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

--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

(if hospital, please include ward name)

Home Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

(if different)

Phone *

Email

Date of Birth *

Sexual Orientation *Sexual OrientationHetrosexual/StraightGay/LesbianBisexualOtherPrefer not to sayNot known by referrer

Ethnicity *EthnicityWhiteMixed/Multiple Ethnic GroupsAsian/Asian BritishBlack/African/Caribbean/Black BritishOther Ethnic GroupPrefer not to sayNot known by referrer

Religion *ReligionBahiBuddhismChristianityHinduismHumanismIslamJudaismPaganismSikhismOtherNo religionPrefer not to sayNot known by referrer

Gender *GenderFemale (incl Trans)Male (incl Trans)IntersexNon-BinaryOtherPrefer not to sayNot known by referrer

Gender same as assigned at birth? *

• Yes
• No
• Prefer not to say

Any disabilities?

• Learning disability
• Mental illness
• Ageing (over 60)
• Dementia
• Physical disability
• Sensory Impairment
• Carer
• Other
• Prefer not to say

Please tick all that apply

Incident date: *

Complaint against: *

Trust:

(e.g. Somerset Partnership NHS Foundation Trust)

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

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

Any important deadlines or meeting dates?

Complaint summary: *

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

• 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

To make a referral to our Somerset Be Heard service, click here