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.

After you fill any of the forms below, please ensure the ”Form Submitted” page opens before you leave the website, otherwise your referral may not be sent to Asist.

Care Act

Make A Referral

1.2 Representative

Make A Referral

IMCA

Make A Referral

IMHA

Make A Referral

NHS Complaints

Make A Referral

Parental Advocacy

Make A Referral - Stoke
Make A Referral - Staffordshire

BAME Advocacy

Make A Referral

Children’s Advocacy
Professional Referral

Make A Referral - Stoke
Make A Referral - Staffordshire

Children's advocacy
Self Referral

Make A Referral

Independent Visitors

Make A Referral

Dementia Advocacy

Make A Referral - Stoke

Care Act Advocacy Referral Form

To provide independent advocacy to facilitate the involvement of a person in:

  • An Adults Needs Assessment
  • Care and Support Planning
  • Review of a Care and Support Plan
  • Safeguarding Enquiry
  • Safeguarding Review
  • Transitions assessments for young people moving from children to adult social care
  • To raise a complaint about or appeal the Care Act process.


The person MUST have a substantial difficulty participating in the process and have no-one willing or appropriate to support them.

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

Referrals can only be made by the person’s social care team, except when the person themselves wishes to make a complaint or appeal.

REFERRAL INFORMATION:

Issue/ task to be address
Substantial difficulty (if ‘No’ is chosen the person will be ineligible for advocacy support)
Please indicate in which of the following areas these needs cause them to have substantial difficulties (tick all that apply):
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 does 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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional
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.
After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

1.2 Representative 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.
1.2 Representative Advocacy Referral Form

ABOUT THE PERSON YOU ARE REFERRING:

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

Notice: Witness statement from a named 1.2 Representative for non-contested Community DoLS. We require the up-to-date Local Authority Care Plan before the case can be allocated, if this is not provided, we will close the referral.

Notice: Request for a named 1.2 Representative for complex or contested Community DoLS, sometimes known as Welfare Orders. We require the up-to-date Local Authority Care Plan before the case can be allocated, if this is not provided, we will close the referral.

Notice: On-going 1.2 Representative for Community DoLS orders that were uncontested and did not require a hearing. Please provide the Court of Protection document confirming the deprivation has been authorised and containing the dates of the deprivation. if this is not provided, we will close the referral.

Notice: On-going 1.2 Representative for Community DoLS orders with complex or contested issues that led to court proceedings, sometimes known as Welfare Orders. Please provide the Court of Protection document confirming the deprivation has been authorised and containing the dates of the deprivation. if this is not provided, we will close the referral.

Further relevant information *
Has lack of capacity being confirmed?
I confirm there is no-one else able or willing to take on the role of 1.2 Representative.
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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional

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.

After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

IMCA Referral Form

To engage and provide support and representation for people who have been assessed to lack capacity regarding a decision for a Serious Medical Treatment, a Change of Accommodation, Safeguarding issues or for Care/Accommodation reviews, and who have NO consultable friends and family.

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

For Safeguarding, Adult Social Care have a duty to refer under the Care Act

Capacity
Has the person been formally assessed to lack mental capacity? (A formal assessment that proves the person lacks capacity regarding the decision under consideration must be done before a referral is made for an IMCA)
Are there any consultable family or friends?
Family/friends are only considered non-consultable if they are (please choose all that apply):

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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional

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 2005 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.

After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional
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.
After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

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. Complaints must be about NHS care and treatment that has taken place in the last 12 months.

Support can only be provided to complainants who are 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:

Please complete this section as fully as possible to prevent a delay in advocacy support.
Summary of the complaint
Issue being complained about (please tick all that apply)
Desired Outcomes, you can choose more than one: (Please note these are the only outcomes available under the NHS Complaints process, if you would like other outcomes you may need to seek alternative support such as legal advice)
Level of Support needed to complete complaint:
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?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional
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.
After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

Stoke-on-Trent Parental Advocacy Referral Form

Parents advocacy assists eligible 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 NOTE, REFERRALS SHOULD BE MADE AT THE POINT A SIGNIFICANT DIFFICULTY IS IDENTIFIED TO ENSURE SUPPORT IS AVAILABLE AT THE EARLIEST POINT IN THE PROCESS (BEFORE IT GETS TO COURT/PLO). REFERRALS AT FINAL PLO STAGE WILL BE REFUSED.

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

Stoke-on-Trent Parental Advocacy Referral Form

ABOUT THE PERSON YOU ARE REFERRING:

REFERRAL INFORMATION:

What process does the person require support with?
Are, or will CSC or CSS be involved?
To be eligible for support the person must have at least one of the following (tick all that apply):
Please indicate in which of the following areas these needs cause them to have substantial difficulties (tick all that apply):
Has the person had a capacity assessment?
Are any of the family/friends appropriate, willing and able to facilitate the person’s engagement in the process/processes and does the individual consent to them being involved?
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
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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional

Disclaimer
Please note, once allocated the advocate will require a minimum of 2 weeks’ notice for any meetings to allow them adequate time to support the person being referred. The advocate may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

Staffordshire Parental Advocacy Referral Form

Parental Advocacy in Staffordshire is available to adults aged 25 and over who:

  • Have assessed Special Educational Needs and Disabilities (SEND), and who had an Education, Health and Care Plan (EHCP) or a Statement of Special Educational Needs that remained in place until the end of their formal education (i.e. was not ceased prior to leaving school or college).
  • Have undergone a cognitive/capacity assessment indicating they lack the capacity to advocate for themselves.
  • Are Parents of Children subject to Child Protection Planning, Early Intervention, or Child in Need Planning.
  • A Social Worker and Team Manager deem through assessment and discussion in supervision that the parent meets the above Eligibility Criteria.
  • Cannot access advocacy sourced through a Court-appointed appointee.


Advocacy support in relation to solicitor interactions or court hearings should be provided by individuals appointed by the court.

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.

Staffordshire Parental Advocacy Referral Form

ABOUT THE PERSON YOU ARE REFERRING:

What process does the person require support with?
Are, or will CSC or CSS be involved?
To be eligible for support the person must have (tick all that apply)
Has the person had a capacity assessment?
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?

FURTHER INFORMATION:

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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional

Disclaimer
Please note, once allocated the advocate will require a minimum of 2 weeks’ notice for any meetings to allow them adequate time to support the person being referred. The advocate may not be able to attend all meetings requested.
Please make sure information on this form is correct before submitting.

After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional
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.
After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

Stoke-on-Trent 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 or supported to raise concerns about involved professionals. The advocacy task must involve either of these two areas for the referral to be eligible.

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.

Stoke-on-Trent Childrens Advocacy Professional Referral Form

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
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:

ADVOCACY TASK

This is a required field. Please select at least 1 category from the dropdown that follows after you check the box above.
Please select all that apply:
Please select all that apply:
Please select all that apply:
Please select all that apply:

Other involved Professionals

The child must be open to Stoke City Council’s Children’s Social Care team. Please provide contact details for their allocated social worker if they are not the referrer.

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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional
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.
After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

Staffordshire Children’s Advocacy Professional Referral Form

To ensure that children and young people in Staffordshire have access to independent advocacy that enables them to:

  • Have a say in decisions affecting their lives and be supported to make their own choices where appropriate
  • Share concerns about their circumstances
  • Be listened to and heard
  • Be treated fairly throughout their involvement with Children and Young People’s Services


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.

Staffordshire Children’s Advocacy Professional Referral Form

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
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:

This is a required field. Please select at least 1 category from the dropdown that follows after you check the box above.
Please select all that apply:
Please select all that apply:
Please select all that apply:
Please select all that apply:

 

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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional
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.
After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

Children’s Advocacy Self-referral Form

You must live in Stoke-on-Trent or have a social worker from Stoke-on-Trent.

If you are a professional you must complete the Childrens Advocacy Professional Referral to ensure we have the correct information to work with the young person.

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)
Are you happy for us to contact them if needed?
Do you go to school or college?
If yes, please provide contact information;
How do you communicate?

Please provide details of your social worker.

Are you happy for us to contact them if needed?

ADVOCACY TASK

The tasks an Advocate can help with include:
1) Supporting you to state your wishes and feelings about decisions which affect you.
2) To raise concerns about professionals who are involved in your care and support.

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?
By submitting this referral I understand that Asist will retain my personal information
At the end of support Asist may contact you for feedback about our services. Please indicate how you would like to be contacted:

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.

After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

Refer a child for an Independent Visitor Referral Form

All Looked After Children are entitled to have access to an independent Visitor to advise and befriend them and the focus should be to facilitate this where it would be in the child or young person’s best interest and is made with their agreement.

Referrals must be made by Staffordshire and Stoke-on-Trent Children’s Social Care

Please ensure you compete this form fully. If the form is not fully completed, this may cause a delay in the allocation for an Independent Visitor.
Independent Visitors Volunteer Application

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
Parent/Carer Details

REFERRAL INFORMATION:

Additional information
Risks: Please select all that apply.

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 young person being referred is deemed to lack capacity, the referrer must indicate they are referring in their best interests.

Does the young person have capacity to consent to this referral?
If yes, has consent been obtained?
Is the referral being made in best interest?
Photos may be taken during outings, all photos will be the property of the young person.
I consent to the young person having their photo taken.

Some activities with higher risks will require the completion of additional consent for the activities (go karting, wall climbing, paintballing, horse riding, meals out if they have allergies etc).

I consent for the young person to participate in activities, pending additional consent for higher risk activities.
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.

After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.

Stoke-on-Trent Dementia Advocacy Form

To support people with dementia and memory impairment to communicate, uphold their rights and fully participate in decisions affecting their lives.

To be eligible for this service you must be:
– 50+
– A resident of Stoke-on-Trent
– Either have a diagnosis of dementia, be seeking a diagnosis or have a memory
impairment.

Self-referrals for Dementia Advocacy can be made along with referrals from family and Health and Social Care professionals.

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.

Stoke-on-Trent Dementia Advocacy Referral Form

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 (if different from above)
Is there a diagnosis of dementia?

REFERRAL INFORMATION:

Has the person been formally assessed to lack mental capacity?
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?
Has consent been obtained?
Is the referral being made in best interest?
At the end of support Asist may contact the advocacy partner and/or the involved professional for feedback about our services. Please indicate any preferences for methods of feedback:
Advocacy Partner
Involved Professional
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.
After pressing "Submit" - Please wait for the page to reload before closing the website, otherwise the referral will not be submitted.