Carer Self-Referral Carer Title*MrMrsMissOther Carer Full Name* Relationship to cared for* Primary condition of cared for* Estimated total hours of caring each week* How long have you had this caring role?* Carer DOB* (DD/MM/YYYY) Carer Age*18-2526- 6465-8485+ Carer Address* Carer Telephone* Carer Mobile Carer Email* Carer Gender*MaleFemaleNon Binary Carer 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 AsianOther- White backgroundWhite BritishWhite Eastern European Carer Employment Status*UnemployedFull time employedPart time employedRetiredUnable to workPrefer not to say Are you a Veteran?*YesNo GP Practice Name* Details of cared for; Most appropriate way to contact carer* Home TelephoneMobileEmail Most convenient time to call carer* If referring on someone’s behalf; Name of the person referring and relationship Contact email address or phone number of person referring I am interested in:Prevent carer breakdownManaging physical / mental healthSkills and understanding of caring roleEmotional SupportSocial activities / Time for selfManaging financesSupport to remain in employmentContingency planningBereavement SupportOther Further information: How did you find out about Gloucestershire Carers Hub: 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.