Capacity Assessment Request Form

Thank you for visiting Clarkston Medical’s capacity assessment page. You have been directed to this page after contacting the practice to request a capacity assessment on one of our patients. Given that capacity can only ever apply to a specific decision at a specific time, we require some more information to understand the decision that you are asking the patient to make, including information about your concerns and the conversations that you’ve had so far with the individual. This approach is taken with reference to the following guide for social and healthcare workers in Scotland:

https://clarkstonmedical.co.uk/wp-content/uploads/2025/08/Capacity-Assessment-Scotland.pdf

Capacity Assessment Request Form

Patient's Full Name(Required)

Patient's DOB(Required)

Date of Request(Required)

Name of Professional requesting assessment(Required)

First Last

Role(Required)

Telephone Number(Required)

Email(Required)

DECISION TO BE MADE(Required)

State the specific decision the individual is being asked to make. Example: The decision under consideration is whether [Name] wishes to return home following discharge from hospital care.

IMPLICATIONS OF A POSITIVE DECISION(Required)

Describe what will happen if the individual agrees or chooses to proceed. Example: If [Name] decides to return home: • They will resume living independently. • Community support services will be arranged (e.g., district nursing, meals on wheels). • There may be risks related to mobility, medication management, or social isolation.

IMPLICATIONS OF A NEGATIVE DECISION(Required)

Describe what will happen if the individual refuses or chooses not to proceed. Example: If [Name] decides not to return home: • Alternative accommodation will be considered (e.g., residential care). • They may lose some autonomy but gain increased safety and support. • Emotional impact of leaving home may be significant.

CONVERSATIONS TO DATE(Required)

Summarize discussions that have taken place around the decision. Example: • On [Date], [Name] discussed the decision with Dr. [Surname]. They expressed concern about managing stairs at home. • On [Date], a meeting was held with family members who supported the idea of returning home with additional support. • On [Date], [Name] spoke with the social worker and asked about care home options. • [Name] has shown fluctuating understanding of the risks and benefits, but has consistently expressed a preference for independence.

WHAT IS YOUR OWN OPINION?(Required)

If you have concerns about the patient's capacity to safely make this decision, can you please give us some explanation or examples as to why you believe this to be the case. This is just to inform our baseline discussion wit the individual, not to hold you to account.