5 Education / training / Workplace / Establishment 9 Hospital – Mental Health 10 Hospital - Community 11 Other 10 Public place If an incident has occurred when did it happen? Who else has been informed of the incident? 1 Police 2 GP 3 CQC 4 CCG 5 Relative if appropriate 6 Advocate 7 Other (please specify) If applicable please provide incident log / crime ref no. 2 Information about the adult you are concerned for: Name: Address: Age / Date of Birth: NHS / LAS number: Telephone: Gender: Male Female Ethnicity: 1 Any other Asian background 2 Any other Black background 3 Any other Ethnic Group 4 Any other Mixed background 5 Any other White background 6 Arab 7 Bangladesh 8 Black – African 9 Black – Caribbean 10 Chinese 11 Gypsy / Roma 12 Indian 13 Information not yet obtained 14 Pakistan 15 Refused 16 Traveller of Irish heritage 17 White – British 18 White – Irish 19 White & Asian 20 White & Black African 21 White & Black Caribbean Other Preferred Language: 1 Arabic 2 Bengali 3 British Sign Language 4 Cantonese 5 Chinese 6 Czech 7 Danish 8 Dutch 9 English 10 Farsi 11 Finnish 12 French 13 German 14 Greek 15 Guajarati 16 Hakka 17 Hindi 18 Hungarian 19 Irish Gaelic 20 Italian 21 Malaysian 22 Patois 23 Polish 24 Punjabi 25 Spanish 26 Urdu 27 Vietnamese 28 Welsh 29 Other GP name / address: GP Tel: Any communication needs: Long term health conditions: (please select all that apply) 1 Chronic Obstructive Pulmonary Disease 2 Cancer 3 Acquired Physical Injury 4 HIV / AIDS 5 Physical Other 11 Sensory Impairment - Visually impaired 12 Sensory Impairment - Hearing impaired 13 Sensory Impairment - Other 14 Learning Disability 15 Autism
6 Stroke 7 Parkinson's 8 Motor Neurone Disease 9 Acquired Brain Injury 10 Neurological Other 16 Asperger’s Syndrome/High functioning Autism 17 Other Learning, Developmental or Intellectual Disability 18 Mental Health Condition - Dementia 19 Mental Health Condition - Other 20 No Relevant Long-Term Reported Health Conditions Details about Capacity, Consent and Advocacy 3 3.1 Does the adult concerned have the capacity to consent to sharing this information? Yes No (If ‘Yes’ please proceed to section 3.2, if ‘No’ please proceed to section 3.3.) 3.2 Does the adult concerned know you are sharing this information? Yes No (If ‘Yes’ please proceed to section 3.4, if ‘No’ please proceed to section 3.3) 3.3 Have you completed a mental capacity assessment? Yes No (If ‘Yes’ please proceed to section 3.5, if ‘No’ please proceed to section 3.6) 3.4 Have they consented? Yes No (If ‘Yes’ Please proceed to section 3.8, if ‘No’ please proceed to 3.9) 3.5 What was the outcome of the Mental Capacity assessment? The person has capacity (Please proceed to section 3.8) 3.6 Why has no mental capacity assessment been undertaken? (Please proceed to section 3.9) 3.7 Best Interest decision (if applicable): If applicable record the advocate / IMCA details here: (Please include any details of relationship to the adult) 3.9 Are you referring in the wider public’s interest? Yes No (If ‘Yes’ please provide details in the space below, if ‘No’ please consider why the referral is being made, contact 01619125135 if you would like to discuss this referral) Adult’s Outcome: 4 What would the adult like to happen following this referral?