Fillable New Referral Form July 19 V3updatedv4reader (Office of the Public Guardian)

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New Referral Form July 19 V3updatedv4reader (Office of the Public Guardian)

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Adults with Incapacity (Scotland) Act 2000
Investigation referral form
Please refer to our guidance for information about making a referral. This explains more about
what we can investigate and what we do. When completing the referral form, provide as much
information and evidence as you can to support your concerns. This will help us establish whether
we have a remit to commence an investigation. We are required by law to report the facts and
circumstances to the local authority if we reasonably consider the adult to be at risk.
1.0 Your details
Name:
Address:
Postcode:
Telephone number:
E-mail address:
Relationship to adult:
Please provide your details if completing this referral in your professional capacity
Job title:
Organisation:
2.1 Details of the adult
Name:
Date of birth:
National insurance number:
Y N Not known
2.2 Adult’s home address
Home address:
Post code:
Is the adult currently living at this address?
Does th
e adult own this property?
Does the adult own any other property?
Is there a charging order on any property?
Tell us about any other property owned by the adult:
1
2.3 Adult’s current address
If the adult is currently living at another address e.g. care home, hospital etc. please tell us:
Name of residence:
Address:
Post code:
Telephone number:
Email address:
Name of person looking after the adult in this place:
Job title:
Date of admission into care:
3.0 About the adult’s capacity
Before completing this section, refer to the guidance note for information around the definition of
incapacity.
In your opinion does the adult have capacity to manage their own affairs? Y N
If the answer is no, it would be helpful if you could give an indication as to when the adult started to
become incapable of looking after their own affairs. It is likely that we will contact the adult’s
general medical practitioner to confirm this information.
4.0 Details of the adult’s general medical practitioner
Name:
Surgery:
Address:
Postcode:
Telephone number:
Email address:
2
5.1 What is the complaint or concern you have?
Please give a brief description of why you believe the adult’s property or financial affairs are, or
might be, at risk. It would be helpful if you could provide as much factual information as you
can and copies of relevant evidence. If you need more space to make your comments, please
use a separate sheet of paper.
5.2 What a
re the known past and present wishes of the adult in relation to the
concern?
6.1 Details of the person causing concern
Name:
Address:
Postcode:
Telephone number:
E-mail address:
Relationship to adult:
Does this person have authority to act on behalf of the adult? Y N
If yes, what authority have they been given? (e.g. attorney, withdrawer, appointee, in receipt of
direct payments for community care services etc.)
If you have a copy of any document, such as a power of attorney, please include it with this form.
3
6.2 Details of any other person causing concern
Name:
Address:
Postcode:
Telephone number:
E-mail address:
Relationship to adult:
Does this person have authority to act on behalf of the adult? Y N
If yes, what authority have they been given?
If you have a copy of any document, such as a power of attorney, please include it with this form.
7.0 Details of the adult’s nearest relative
Name:
Address:
Postcode:
Telephone number:
E-mail address:
Specific relationship to adult: (son, daughter, spouse, cousin etc.)
8.0 Details of the adult’s social worker / mental health officer
If the adult has a social worker or a mental health officer, please complete the details below.
Name:
Job title:
Local authority and department:
Address:
Postcode:
Telephone number:
E-mail address:
• Go to section 9 if the referral is being made by the local authority
• Go to section 10 if the referral is being made by any other person
4
This section should only be completed if the referral is being made
by local authority staff
9.1 Personal welfare
Is there a concern in relation to the adult’s personal welfare? Y N
If so have you notified the Mental Welfare Commission? Y N
Please provide any details below if the concern about personal welfare directly relates to this
referral.
9.2 Adult Support & Protection (ASP)
Please confirm that you have reported the circumstances of this referral to your specialist ASP
team?
If a referral was made what action, if any, has been taken? If you need more space to make your
comments, please use a separate sheet of paper.
9.3 Additional information
Please provide a summary of other information such as:
• Details of any other form of income known e.g. pension, benefits, allowances or income from
renting property etc.
• Details of any financial assessment carried out
• Is the adult in receipt of their personal allowance?
• Is an appointee or corporate appointee is receiving funds on behalf of the adult?
• Would the local authority be prepared to apply to be an appointee or apply for some other form
of authority e.g. guardianship?
5
10.0 Referral made by:
Signature:
Date:
When we receive the form and supporting evidence we will review all of the information to allow us
to reach a view on the matter. If we are unable to investigate, we will contact you to let you know
and explain why.
If we are able to investigate, we may contact you to obtain further information to assist with our
enquiries. Please be aware that we do not provide ongoing updates as to case progress. However,
we will contact you to advise when we reach a final view.
11.0 Our co
ntact details
Please send the completed referral form along with any supporting evidence to us at the postal or
email address below:
Office of the Public Guardian (Scotland)
Investigation Team
Hadrian House
Callendar Business Park
Callendar Road
Falkirk
FK1 1XR
DX 550360 Falkirk 3
• Telephone: 01324 678350
• E-Mail: POA-INV@scotcourts.gov.uk
• Website:
www.publicguardian-scotland.gov.uk
• Opening hours: 9am – 5pm Monday to Friday
Draft combined ref form/ AK/Aug19/v3
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New Referral Form July 19 V3updatedv4reader (Office of the Public Guardian)

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Completed 16 July 2020

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