Greater Manchester Culturally Appropriate Advocacy Service

This is a referral form for Greater Manchester's culturally appropriate advocacy service provided by Gaddum. We work with people from a racially minoritised background (Black, Asian, Arab and ethnic minority people) that have experienced inpatient mental health care or who are at risk of detention under the Mental Health Act.

Who is making this referral?

DETAILS OF PERSON BEING REFERRED TO CULTURALLY APPROPRIATE ADVOCACY:

First Name*

Last name*

Phone number (mobile or landline)*

Email address

First line of address*

Second line of address

Town

Postcode*

If the person being referred is somewhere different to their home address for example this could be a hospital or a friend's address, please provide this address here:

First line of address

Second line of address

Town

Postcode

What is the main language of the person being referred?*

What is the gender of the person being referred?*

Is the gender identity of the person being referred the same as they were given at birth? (e.g you were assigned male at birth do you still indentify as male) *

What is the sexual orientation of the person being referred?*

What is the date of birth of the person being referred?*

How would you describe the ethnicity of the person being referred?*

If you selected 'other' please describe here

What is the religion of the person being referred?*

Please tell us about any access needs the person being referred has that could help us work together? This for example could be an interpreter, arranging meetings in a wheelchair accessible space, or any other needs the person being referred may have?*

If there are there any known risks that professionals need to be aware of when working with this individual, please describe:*

Please confirm the person being referred consents to us holding their personal information for the purpose of providing Advocacy Services.
If you are filling this form out online please tick 'yes - written'

If you tick 'lacks capacity - best interest referral' you confirm that the person being referred is deemed to lack the capacity to consent to this referral, you must indicate this referral has been made in their best interest.

Consent to store information*

Where is the person being referred currently staying? *

Which of the following best describes the person being referred in relation to their mental health care treatment?*

If the person being referred is currently detained ("sectioned") under the Mental Health Care Act, when did this begin?

Is the person being referred currently planning their aftercare treatment for when they leave hospital?*

What does the person being referred want their advocate to help with?*

In the past, has the person being referred accessed Advocacy services OR are they currently working with an Independent Mental Health Advocate? (IMHA)*

REFERRER INFORMATION
If you have completed this form on behalf of someone please fill in your information here:

What is the referrers name?*

Referrers telephone number*

Referrers email address*

Job Title

Are there any current safeguarding concerns we should be aware of?*

Details of safeguarding