Refer a Carer All questions marked with an asterisk-*- are required Carers Details: 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 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 Most appropriate way to contact carer/ most convenient time to call* GP name, Tel no. and Practice address: Does the carer have any communication needs?* 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 Information from Gloucestershire Carers Hub on your privacy We collect and use your personal information to provide carer support services effectively and to meet our statutory duties under the Care Act 2014 and other relevant legislation. We will collect only the personal information we need to perform our duties. We will collect your name and contact details as well as information relevant to your support needs. The Gloucestershire County Council and PeoplePlus Privacy Notice outlines the types of information we are required to capture, the reasons for this, and our commitments to privacy regarding all information that we hold. As a referrer you should provide a copy of our Privacy Notice, either electronically or in hard copy, to the carer. Our Privacy Notice can be found here. Please tick to confirm that you have provided the carer with details of our Privacy Notice. Carers Caring Details: Condition(s) of cared for?* Who are they providing care for?* What is the Primary Condition of the person they provide care for?* How long has the Carer provided this caring role?* Estimated total hours of caring each week* What type of support does the Carer provide?* Initial concerns and the reason for the referral?*Prevent carer breakdownSocial activities / Time for selfManaging physical / mental healthManaging financesSkills and understanding of caring roleSupport to remain in employmentEmotional supportContingency planning 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* Professional referral/Current intervention: Have you visited the carer's home?YesNO Detail in comments any concerns/hazards to be aware of What has your service already put in place to support this Carer? How long have you been involved with/aware of this carer or the person(s) they care for?