Please Complete and Return To: Total Voice Northamptonshire, Voiceability
Please complete and return to: Total Voice Northamptonshire, VoiceAbility,
Doddridge Centre, 109 St James Road, Northampton, NN5 5LD
Tel:020 3355 8846│ Fax: 01604 805871
Email:
About the ReferrerAbout the referrer
Date: / Referral Team:
Name of person making the referral: / Organisation the referrer works for:
Job Title: / Telephone number:
Email address:
About the Person
Name of person requiring support: / Telephone number:
Date of birth:
Address:
E-mail address: / Preferred contact method:
Preferred language: / Any other communication needs:
Consent
Where appropriate, have you discussed the referral to advocacy with the person?(If no, we will contact you prior to making contact with the person.) / Yes / No
Has the person agreed to this referral being submitted? / Yes / No
Signature of referrer: / Signature of client (if possible):
Referral Details
Is the referral for: / Please tick / Referral Category / Please tickAn adult with care & support needs / Assessment
A carer with support needs / Planning
A young person with care & support needs, going through transition. / Review
A young carer with support needs / Safeguarding
Advice and Information
Background and Additional Information
Care and Support needs:Please detail any support needs the advocate needs to be aware of to provide advocacy e.g. any long term condition or impairment.
Nature of Substantial Difficulty(please tick each relevant box)
Understanding relevant information / Retaining information
Using or weighing up information / Communicating their views wishes and feelings
Where possible, please elaborate on what difficulties that person has in being fully involved in the process including any concerns that the person may lack capacity to make some decisions in relation to their care and support.
What additional support, if any, is available to the person?
Risks - please detail any information needed to ensure the safety of the advocate and the referred person during the advocacy process
Any other relevant information / specific needs:
Equal Opportunities
Completing on Behalf of Referred PersonIf the referred person is unable to indicate the information below due to limited communication or lacking capacity around these questions, and you as the referrer have completed on their behalf, please tick the box to the right.
Name: / Date:
Do you consider yourself:
Male / Transgender / Female / Prefer not to say
How would you describe your ethnic origin or background?
White British / English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background, please write in
Mixed and Multiple Ethnic Groups / White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple Ethnic background, please write in
Asian / Asian British / Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background, please write in
Black / African/ Carribean / Black British / African
Caribbean
Any other Black / African / Caribbean background, please write in
Other Ethnic Group / Arab
Any other ethnic group, write in
Prefer not to say
How would you describe your sexuality?
Heterosexual / Straight / Homosexual / Gay/Lesbian / Bi-sexual / Prefer not to say
How would you describe your religious beliefs?
No Religion / Jewish
Christian / Muslim
Buddhist / Sikh
Hindu / Any other religion, please specify
Prefer not to say
Do you consider yourself to have? (Tick all that apply)
A Learning Disability / Mental Ill Health
A Physical Disability / A Sensory Impairment
Dementia / Autism
An Acquired Brain Injury / Physical Ill Health
Prefer not to say / Other (Please specify)
Northamptonshire Care Act Advocacy Referral Form – August 2016
Registered Charity 1076630 Limited Company 3798884