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:

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 name (required)

Date of birth (required)

Gender
MaleFemaleOther

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

Landline

Mobile

Email address (required)

Is it ok to leave a message?
YesNo

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

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 name

Their date of birth

Their gender
MaleFemaleOther

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 & Newsletter

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 info@carershub.co.uk to remove your personal information from our database.
I Agree