Mental Capacity Reasoning Form

Service User's Name

First Last

Date of Birth

Weeks Gestation

Advocate's Name

First Last

Staff Member's Name

First Last

Capacity Decision & Rationale

An assessment has been made that the above service user does not have the capacity to provide informed consent directly

Following an assessment made by our staff member (named above) and the service users’ representative (named above – if present), the decision has been made to / not to continue with the provision of the booked service. This decision has been based on the following information and observations

I confirm that the above decision has been made taking in to account the best interests of the person in question, their personal circumstances, religious beliefs, the permanency of the condition impacting their capacity and the benefits and/or risks that the service presents to them as an individual. It is our belief that this decision doesn’t pose any harm to the individual.

Signatures

Signed by Staff Member

Date (Staff)

Signed by Representative / Advocate (if present)

Date (Representative/Advocate)

Signed by Service User

Date (Service User)

Representative / Advocate Details

Telephone Number

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of Birth

Are you Power of Attorney?

Yes