Completing this form

*Mandatory fields MUST be completed.

By completing this referral form you are requesting the support of an Independent Professional Advocate (IPA). An IPA can support an individual to understand the information they receive and express their own views, wishes and feelings within professional meetings. Is this the service you require? *

Section 1: About the person who requires advocacy

First Name: *

Last Name: *

Title:

Preferred name / known as:

Gender: *

Gender if wishing to self describe:

Current Address: *

Previous Address (if recent):

Age group: *

Contact telephone number(s): *

E-mail address:

Communication preference (tick all that apply):

Phone	Text
Email	Post

Communication requirements or preferences:

Please select the best description of the individual's needs: *

Does the individual know anyone who can advocate further? (Family, friends, etc.):
This cannot be someone who has a conflict of interest, someone the individual doesn’t want involved, is unable to adequately offer support or is currently involved in an enquiry of abuse or neglect. *

No	Yes (please state) Yes (please state)

Is there or has there been any historical events/incidents which may put the individual or others at risk? (Illegal activities, sexual/non-sexual violence or threat, substance misuse, Domestic abuse, etc.): *

Section 2: About the advocacy issue

Does the individual have social care and support needs? *

Does the individual care for someone who has social care and support needs? *

Please give an overview of the individual’s current issue and why advocacy is required: *

Advocates have a duty to share information with the people they support. Please indicate any reason why we should not do this:

What would be the person’s desired outcome(s) from the advocacy support received? *

Section 3: About the person referring - If you are referring yourself please put “self referral” in the first box and go to section 4

Name of referrer: *

Team you belong to (if applicable):

Social Services ID Number or WCCIS Number

Referrer address:

Referrer telephone number(s):

Referrer’s e-mail address:

In what capacity do you know the individual and for how long:

Section 4: Social Worker or Care Manager information

Name of Social Worker or Care Manager:

Their role/title:

Address:

Phone number:

Email address:

Section 5: Other professionals

Name of any other relevant professional, e.g. CPN, Psychiatrist, GP, Probation Officer:

Their role/title:

Address:

Phone number:

Email address:

Use the space below to provide any further details of people currently or recently working with the individual, e.g. CPN, Psychiatrist, GP, Probation Officer:

Section 6: If you are supporting someone to make a self referral

Only complete this section if you are supporting someone to complete this form as a self referral. Skip to section 7 otherwise.

If you are supporting someone to complete this form as a self-referral, please provide your Name:

Your phone number:

Your email address:

Section 7: Consent

Has the individual consented to the referral? *

Does the individual lack capacity to consent to the referral? *

If the individual lacks capacity to consent, is this referral made in the person’s best interests? *

Does the individual consent for Dewis CIL to store this referral and its data for the purpose of identifying and providing support? *

Dewis CIL operates an open access policy on all records and we expect the individual to agree to a referral being made, providing they have the capacity to do so. This is important to ensure advocacy is effective, transparent and independent.

Welsh	English	Other spoken language
BSL	Easy read	Non-verbal communication
Communication aids	Other Other

Acquired brain injury	Adult at risk
Autism spectrum disorder	Hearing impairment
Mental health illness	Older person
Physical disability	Substance misuse
Vision impairment	Carer
Learning disability	Other Other