Referrals

Advocacy services in Staffordshire &
Stoke-on-Trent 

Referrals

Make a referral

As a professional, you may encounter situations where it is necessary to refer an individual for advocacy services to ensure they receive appropriate support. In these cases, please use our referral forms to provide the necessary details efficiently. Alternatively, you can contact us directly for assistance or guidance on how to proceed. Our team is here to help streamline the referral process and ensure that those in need get the advocacy services they require.

Care Act

Make A Referral

DoLS & Paid Representation

Make A Referral

IMCA

Make A Referral

IMHA

Make A Referral

NHS Complaints

Make A Referral

Parental Advocacy

Make A Referral

BAME Advocacy

Make A Referral

Children’s Advocacy
Professional Referral

Make A Referral

Children's advocacy
Self Referral

Make A Referral

Independent Visitors

Make A Referral
We work alongside people, supporting them to have their voices heard and be part of any decisions made about their care and support. Our services are free and confidential.

Contacts Info

0300 800 1000

[email protected]

Send us a text: 60777

Policies

Privacy policy

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Asist Advocacy Services is a registered charity number: 1048075
Asist is a company registered in England – company number: 3068125

Care Act Advocacy Referral Form

To provide independent advocacy to facilitate the involvement of a person in their assessment, preparation of a care plan, in safeguarding enquiries, safeguarding adults reviews, carers assessment and reviews, and transition assessments for young people transitioning into adult social care.

Care Act referrals MUST be made by the person’s social care team.

Please ensure you compete this form fully. If the form is not fully completed, this may cause a delay in the allocation for an advocate.
Care Act Advocacy Referral

ABOUT THE PERSON YOU ARE REFERRING:

Is the person’s current address
Disability or impairment
Gender
Pronouns
Sexual orientation
How does the person communicate?
Ethnic origin
Religion or belief
Does the person identify as having a disability or long-term health condition?

ABOUT YOU:

Referrer Details

REFERRAL INFORMATION:

Issue/ task to be address
Substantial difficulty
Capacity
Has the person been formally assessed to lack mental capacity?
Family and friend involvement
Does the person have an appropriate adult willing and able to facilitate their involvement in the process/ processes and dose the individual consent to their involvement?
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.

If the person being referred is deemed to lack capacity, the referrer must indicate they are referring in the person’s best interest.

Does the person have capacity to consent to this referral?
If yes, has consent been obtained?
Is the referral being made in best interest?
Disclaimer
Please note where possible, provide us with 2 weeks’ notice for any meetings to allow the advocate adequate time to support the person being referred. We may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

Community DoLS Advocacy Referral Form

To help the person understand their authorisation and how it affects them, and to support them to exercise their rights.

Referrals are only accepted from the person’s adult social care team.

Please ensure you compete this form fully. If the form is not fully completed, this may cause a delay in the allocation of an advocate.
Community DoLS Advocacy referral

ABOUT THE PERSON YOU ARE REFERRING:

Is the person’s current address
Disability or impairment
Gender
Pronouns
Sexual orientation
How does the person communicate?
Ethnic origin
Religion or belief
Does the person identify as having a disability or long-term health condition?

ABOUT YOU:

Referrer Details
Adult Social Care (ASC) assessor details
REFERRAL INFORMATION:
Type of process
Please provide the prosed care plans and assessment relating to the deprivation.
Substantial difficulty
Has a capacity assessment been carried out?
Does the person have an appropriate adult willing and able to facilitate their involvement in the process/processes and dose the individual consent to their involvement?
Significant dates
Risks
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.

If the person being referred is deemed to lack capacity, the referrer must indicate they are referring in the person’s best interest.

Does the person have capacity to consent to this referral?
If yes, has consent been obtained?
Is the referral being made in best interest?

Disclaimer
Please note where possible, provide us with 2 weeks’ notice for any meetings to allow the advocate adequate time to support the person being referred. We may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

IMCA Referral Form

To engage and provide support and representation for people who have been assessed to lack capacity and who have no-one else to support them when major, potentially life changing decisions are being made.

Referrals must be made by the decision maker, or someone authorised by them.

Please ensure you compete this form fully. If the form is not fully completed, this may cause a delay in the allocation of an advocate.
IMCA Referral

ABOUT THE PERSON YOU ARE REFERRING:

Is the person’s current address
Disability or impairment
Gender
Pronouns
Sexual orientation
How does the person communicate?
Ethnic origin
Religion or belief
Does the person identify as having a disability or long-term health condition?

REFERRAL INFORMATION:

Decision type
(Adult Social Care should refer under the Care Act as they have a duty to instruct)
Capacity
Has the person been formally assessed to lack mental capacity?
Please confirm there are no known consultable family or friends.

ABOUT YOU:

Referrer Details
Person responsible for the best-interest decision (Decision maker)
Who to contact to arrange visit? (if different to above)
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.

If the person being referred is deemed to lack capacity, the referrer must indicate they are referring in the person’s best interest.

Does the person have capacity to consent to this referral?
If yes, has consent been obtained?
Is the referral being made in best interest?
Disclaimer
Please note where possible, provide us with 2 weeks’ notice for any meetings to allow the advocate adequate time to support the person being referred. We may not be able to attend all meetings requested.
For serious medical decisions, the Mental Capacity Act 2015 states that where an urgent decision needs to be made (to save someone’s life) a responsible body does not need to instruct an IMCA but should refer for any serious treatment that follows the emergency treatment. Also they should not delay treatment while waiting for the IMCA’s report and should act in best interests.
Please make sure information on this form is correct before submitting.

Independent Mental Health Advocacy Referral Form

To support qualifying patients to understand the legal provisions to which they are subject to under the Mental Health Act 1983, to understand the rights and safeguards they are entitled to and to exercise their rights through supporting their participation in decision-making.

Please ensure you compete this form fully. If the form is not fully completed, this may cause a delay in the allocation of an advocate.

Independent Mental Health Advocacy Referral

ABOUT THE PERSON YOU ARE REFERRING:

Disability or impairment
Gender
Pronouns
Sexual orientation
How does the person communicate?
Ethnic origin
Religion or belief

ABOUT YOU:

Referrer Details

REFERRAL INFORMATION:

Has a Tribunal been applied for?
Issue/task to be addressed
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.

If the person being referred is deemed to lack capacity, the referrer must indicate they are referring in the person’s best interest.

Does the person have capacity to consent to this referral?
If yes, has consent been obtained?
Is the referral being made in best interest?
Disclaimer
Please note where possible, provide us with 2 weeks’ notice for any meetings to allow the advocate adequate time to support the person being referred. We may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

Independent Health Complaints Advocacy Referral Form

To provide guidance, to empower and support people who wish to make a complaint about the service they have received from the NHS, whether directly provided or commissioned by the NHS.

Referrals can only be accepted from residents of Stoke-on-Trent or Staffordshire.

Independent Health Complaints advocacy referral

ABOUT YOU:

Details of the person making the complaint (complainant)
Preferred method of communication
Do we have permission to leave a message? (Telephone)
Details of the patient (if different from the above)
Preferred method of communication
Do we have permission to leave a message? (Telephone)
If you are a professional making the referral

ABOUT THE PERSON:

Disability or impairment
How does the person communicate?

REFERRAL INFORMATION:

Details of the complaint
Issue being complained about (please tick all that apply)
Diversity monitoring
By completing the information below you can help us ensure our services reach everyone who needs them and inform how we might improve our service provision.
Gender
Pronouns
Sexual orientation
Ethnic origin
Religion or belief
Does the person identify as having a disability or long-term health condition?
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.

I agree to Asist holding my personal information.
If the person being referred is deemed to lack capacity, the referrer must indicate they are referring in the person’s best interest.
Does the person have capacity to consent to this referral?
If yes, has consent been obtained?
Is the referral being made in best interest?
Disclaimer
Please note where possible, provide us with 2 weeks’ notice for any meetings to allow the advocate adequate time to support the person being referred. We may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

Parental Advocacy Referral Form

Parents advocacy assists parents who have a difficulty being involved in the process to fully engage in assessments and to understand the complex statutory processes within Children’s Social Care, where there is no one appropriate or available to facilitate and represent their views.

Referrals will only be accepted from the Stoke-on-Trent City Council Social Care Staff and must be signed by the Authorising Manager.

Please ensure you compete this form fully. If the form is not fully completed, this may cause a delay in the allocation of an advocate.
Parental Advocacy Referral

ABOUT THE PERSON YOU ARE REFERRING:

Disability or impairment
Gender
Pronouns
Sexual orientation
How does the person communicate?
Ethnic origin
Religion or belief
Does the person identify as having a disability or long-term health condition?

ABOUT YOU:

Referrer Details

REFERRAL INFORMATION:

What process does the person require support with?
Are, or will CSC or CSS be involved?
Family and friend involvement
Does the person have an appropriate adult willing and able to facilitate their involvement in the process/ processes and does the individual consent to their involvement?

ABOUT YOU:

Referrer Details
Manager’s Authorisation
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.

If the person being referred is deemed to lack capacity, the referrer must indicate they are referring in the person’s best interest.

Does the person have capacity to consent to this referral?
If yes, has consent been obtained?
Is the referral being made in best interest?
Disclaimer
Please note where possible, provide us with 2 weeks’ notice for any meetings to allow the advocate adequate time to support the person being referred. We may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

Black, Asian and Minority Ethnicities Advocacy Referral Form

(We understand the terms BME and BAME are outdated and no longer used by many organisations. We only use it here as it reflects the wording used in our current contract and data reporting).

To provide one to one advocacy for people over the age of 18 from black minority and ethnic communities.

Please ensure you compete this form fully. If the form is not fully completed, this may cause a delay in the allocation for an advocate.

Black, Asian and Minority Ethnicities Advocacy Referral

ABOUT THE PERSON YOU ARE REFERRING:

Is the person’s current address?
Disability or impairment
Gender
Pronouns
Sexual orientation
How does the person communicate?
Ethnic origin
Religion or belief
Does the person identify as having a disability or long-term health condition?

REFERRAL INFORMATION:

What issue does the person need help with?

ABOUT YOU:

Referrer Details
Self- Referral (please skip to consent)
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.

If the person being referred is deemed to lack capacity, the referrer must indicate they are referring in the person’s best interest.

Does the person have capacity to consent to this referral?
If yes, has consent been obtained?
Is the referral being made in best interest?
Disclaimer
Please note where possible, provide us with 2 weeks’ notice for any meetings to allow the advocate adequate time to support the person being referred. We may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

Children’s Advocacy Professional Referral Form

To ensure that looked after children and young people in Stoke-on-Trent are supported in advocating their wishes and feelings in decisions which affect them. Please ensure you compete this form fully. If the form is not fully completed, this may cause a delay in the allocation of an advocate.
Children’s Advocacy Professional referral

ABOUT THE PERSON YOU ARE REFERRING:

Is the person’s current address
Is the child/ young person currently attending school or college?
Disability or impairment
Gender
Pronouns
Sexual orientation
Ethnic origin
Religion or belief
Does the person identify as having a disability or long-term health condition?

ABOUT YOU:

Referrer Details

REFERRAL INFORMATION:

In Children’s legislation, which category does the child or young person fall under?
Looked After Children
Children with Disabilities (or siblings where there is a need to do so) supported by Stoke children with Disabilities Team
Child Protection Plans or a Children In Need (CPP or CIN)
Children and Young people with Special Educational Needs and Disabilities (SEND) in relation to issues related to the Education, Health and care planning process
Please tick the box if it applies
Please tick the box if it applies

Other involved Professionals

Role: CSC Social Worker

Role: Team Manager

Role: IRO

Role: Key Worker

Role: PA, Leaving care

Role: Adult SW, leaving Care

Substantial difficulty
Has a capacity assessment been carried out?
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.

If the person being referred is deemed to lack capacity, the referrer must indicate they are referring in the person’s best interest.

Does the person have capacity to consent to this referral?
If yes, has consent been obtained?
Is the referral being made in best interest?
Disclaimer
Please note where possible, provide us with 2 weeks’ notice for any meetings to allow the advocate adequate time to support the person being referred. We may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

Children’s Advocacy Self-referral Form

You must live in Stoke-on-Trent or have a social worker from Stoke-on-Trent.
Children’s Advocacy self-referral form

ABOUT YOU

What is your current living arrangement?
(what is their name, phone number and address, if different from yours)
Do you go to school or college?
If yes, please provide contact information;
How do you communicate?

ARE THERE ANY PROFESSIONALS INVOLVED IN YOUR LIFE?

OTHER
Diversity monitoring
By completing the information below you can help us ensure our services reach everyone who needs them and inform how we might improve our service provision.
What is your gender
Pronouns
What is your sexual orientation
What is your ethnic origin
What is your religion or belief
Do you have a disability or long-term health condition?
Consent - I agree to Asist holding my personal information.
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.
Disclaimer
Please note where possible, provide us with 2 weeks’ notice for any meetings to allow the advocate adequate time to support the person being referred. We may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

Independent Visitors Volunteer Application

We are currently recruiting Independent Visitors for our ever-expanding service and are looking for anyone who thinks they have the skills, time and energy to devote to a child in care. Full training and ongoing support will be given, and out of pocket expenses paid for mileage and activities.

Applicants must be over 21 and be able to commit to meet with the child or young person for two hours once a month for a minimum period of 12 months. They must be able to work well with children and young people and be reliable.

Independent Visitors Volunteer Application

ABOUT THE VOLUNTEER ADVOCATE:

Have you been an Independent visitor before?
Driving (Tick all that apply)
Employment status
Name: Tel No: Email: Address: Relationship to you:
Gender
Pronouns
Sexual orientation
Communication
Checkboxes
Religion or belief
Do you identify as having a disability or long-term health condition?
Do you require any reasonable adjustments from Asist?
Consent
Due to GDPR (2018), we need authorisation to say that people agree to Asist holding their personal information included on this form.
I confirm that the information on this referral is correct.
Do you have a criminal background?
I consent to an enhanced DBS check.