Refer a Carer

Carers Details:

Title*MrMrsMissMsOther

Full Name*

Known as

Home Address*

Tel No.*

Mobile

Email (or n/a)

DOB* (DD/MM/YYYY)

Age*18-2526- 6465-8485+

Gender*MaleFemaleNon Binary

Employment Status*UnemployedFull time employedPart time employedRetiredUnable to workPrefer not to say

Is the Carer a Veteran*YesNo

Ethnicity*Any other ethnic groupAny other mixed backgroundAsian/ Asian British- BangladeshiAsian/ Asian British- PakistaniAsian/ Asian British-IndianBlack - other backgroundBlack/ Black British- AfricanBlack/ Black British- CaribbeanChineseGypsy or Irish TravellerMixed- White & AsianMixed- White and Black CaribbeanWhite and AsianNot obtained/ refusedOther- White backgroundWhite BritishWhite Eastern European

GP name, Tel no. and Practice address:

Does the carer have any communication needs?* (e.g. hearing impairment, visual impairment, translation services required.) Please note that translation services can be arranged for a carer, please specify which language translation is required.

Will the carer experience substantial difficulty in understanding, retaining or using information given, or in communicating their views, wishes or feelings? If so, consider if advocate needed - please indicate this need below

Carers Caring Details:

Condition(s) of cared for?*

Who are they providing care for?*

How long has the Carer provided this caring role?*

Estimated total hours of caring each week*Under 10 hours per week10 - 20 hours per week21 - 35 hours per week36 - 50 hours per week51+ hours per week

What type of support does the Carer provide?*

Initial concerns and the reason for the referral?*:Prevent carer breakdownManaging physical / mental healthSkills and understanding of caring roleEmotional SupportSocial activities / Time for selfManaging financesSupport to remain in employmentContingency planningBereavement SupportOther

Please provide any further information*

Referrer Details

Name of referrer*

Job title*

Name of GP surgery/ Organisation/ Agency (If statutory service please specify team and location)*

Email*

Tel No Numbers only*