Self Referral

If you are an adult carer and would like to refer yourself for our services you can complete our self referral form below.

If it is support/services for the person you care for that is needed, please request an adult social care assessment on their behalf instead/aswell.

Alternatively you can contact us directly on 01273 977 000 and speak to anyone in the team. We are here to help you.

If you are a professional and wish to refer an adult carer, aged 18 or over, please complete our adult carers referral form for professionals.

    About You

    Your first name (required)

    Your last name (required)

    Date of birth (required)

    Your Gender (required)

    Please specify:

    Is your gender identity the same as the gender your were assigned at birth?
    YesNoPrefer not to say

    Sexual orientation (required)

    Please specify:

    Preferred pronouns (e.g. she/her/hers)

    Ethnicity (required)

    Please specify:

    Employment status (required)

    Address including postcode (required)

    If you have an unpaid caring role for someone over the age of 18 who has a long-term illness or disability, please complete the form below.

    Your contact details



    Email address (required)

    Is it ok to leave a message?

    Do you have any sensory or communication needs e.g. interpreting?

    If Yes, please say what needs you have

    Have you had an assessment of your needs as a carer
    (e.g. from the Council’s Access Point or a social worker)?
    YesNoDon't know

    About the person you are looking after

    Their first name (required)

    Their last name (required)

    Their date of birth (required)

    Their gender (required)

    Please specify:

    Is their gender identity the same as the gender they were assigned at birth?
    YesNoPrefer not to sayUnknown

    Their sexual orientation (required)

    Please specify:

    Their preferred pronouns (e.g. she/her/hers)

    Their ethnicity (required)

    Please specify:

    Their address, if different from yours

    What is their relationship to you
    e.g. are they your parent/partner/friend?

    Please tell us their health condition and how it affects them

    Their GP surgery

    Are there any services or agencies involved
    e.g. a care agency/Crossroads respite service?

    How can we help you?

    We provide a wide range of services and activities for carers.
    All our services are free to carers.

    Please tell us what sort of support might be helpful to you in your caring role:

    Other – please tell us what else might help

    Where did you hear about us? (required)

    Please specify

    Data Protection

    In order to proceed with your referral, we will need to add your and the cared for person's details to our database. We will only use your and their personal information to provide you with information and signpost you to other services that relate to your caring role. You and the cared for person can change your mind at any time by contacting to remove your personal information from our database.
    I Agree