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Carer Details
Today’s Date*
Your Surname*
Your First Name*
Your Address, line 1*
Your Address, line 2
Town
County
Postcode*
Date of Birth*
Main Telephone No.*
Your Email Address
Do you have access to the internet?*
Please select an option
Full
Limited
None
Your GP Surgery
Please select an option
Your Gender
Please select an option...
Man (including trans man)
Woman (including trans woman)
Trans
Non Binary
Prefer not to Say
Unsure
Prefer to Self-Describe
Gender, if you would prefer to self-describe
Ethnicity*
Please select an option
Sexual Orientation
Please select an option
Heterosexual
Gay Or Lesbian
Bisexual
Prefer To Self-Describe
Unsure
Prefer Not To Say
Preferred Pronouns
Please select an option
She/Her
He/Him
They/Them
Prefer to Self-Describe
Preferred Pronouns - Prefer to Self-Describe
Employment Status
Please select an option...
Yes (Full Time)
Yes (Part Time)
Self Employed
Student
Volunteering
Not In Paid Work
Wishing To Return To Work
Retired
Do you need an interpreter and/or translated materials?
Please select an option
Interpreter AND Translation Required
Interpreter Required
Translation Required
No
Preferred Language (if not English)
Do you have any other communication needs? (No voicemails, large print, etc.)
Please select the main reason for which the person you care for needs your support
Please select an option
Support Someone Who Is Frail/Elderly
Support Someone With An Autistic Spectrum Condition
Support Someone With A Learning Disability
Support Someone With A Substance Misuse Issue
Support Someone With A Mental Health Condition
Support Someone With A Physical Disability
Support Someone With A Physical Illness
Support Someone With A Life Limiting Illness
Support Someone With An End Of Life Condition
Support Someone With Memory/Cognition Problems
Support Someone With A Mild Cognitive Impairment
Support Someone With Dementia
Do you have any health conditions or additional needs yourself you would like us to be aware of?
Cared-for Details
Their Surname*
Their First Name*
Please state their relationship to you*
Their Address – if different to yours, line 1
Their Address, line 2
Town
County
Postcode
Their Date of Birth*
Their GP surgery
Their Gender*
Please select an option...
Man (including trans man)
Woman (including trans woman)
Trans
Non Binary
Prefer not to Say
Unsure
Prefer to Self-Describe
Their Gender, if they prefer to self-describe
Preferred Pronouns
Please select an option
She/Her
He/Him
They/Them
Prefer to Self-Describe
Preferred Pronouns - Prefer to Self-Describe
Please select the main condition for which this person receives support*
Please select an option
Acquired Brain Injury
Adhd
Allergy
Amputee
Arthritis
Asthmatic
Autistic Spectrum
Back Problems
Bowel Condition
Cancer
Cerebral Palsy
Challenging Behaviour
Crohn's Disease
Cystic Fybrosis
Dementia
Diabetes
Diet
Digestive Problems
Dyslexic
Dysphasia
Dyspraxia
Eating Disorder
Eczema
Ear nose, throat Condition
Epilepsy
Fibromyalgia
Hay Fever
Head Injuries
Hearing Impairments
Heart Conditions
High Blood Pressure
Huntingtons Disease
Hypermobility
Learning Difficulties
Lupus
M.e.
Memory/Cognition Problems
Mental Health
Migraines
Mobility Issues
Motor Neurone
Multiple Sclerosis
Muscular Dystrophy
Musculo Skeletal (Msk)
Neurological
Obesity
Organ Failure
Other
Paraplegic
Parkinson's Disease
Polio
Post-COVID Syndrome
Prader-Willi Syndrome
Raynaud's Syndrome
Respiratory Conditions
Speech Impairment
Spina Bifida
Spinal Injury
Stroke And Aphasia
Substance Misuse
Thalidomide
Thyroid
Tourettes Syndrome
Visual Impairments
Please note any additional health conditions you’d like us
to be aware of, or, if ‘other’ selected from dropdown, please describe.
Is the person you care for receiving support from any other services?
Please select an option
Yes
No
Do Not Know
If yes, please give a brief description of services’ involvement
About your caring role
Please use this space to describe your caring role and any support for yourself which may be of interest
Are you aware of any reason our staff should not conduct a home visit? If yes, please give details*
Are there any other risks or safeguarding issues we should be aware of? If yes, please give details
Consent Given
In order to proceed with your referral, The Carers Centre will add the details provided above to our database. We will only use the data supplied to provide you with information and signpost you to relevant services. You and the person you support can withdraw consent at any time by contacting
info@carershub.co.uk*
Please select an option...
Yes
No
GDPR preferences
Please be aware that choosing ‘block’ to any of these options may delay the processing of your referral.
Contact Preferences
Telephone*
Please select an option
Allow
Block
E-Mail*
Please select an option
Allow
Block
Text Messages*
Please select an option
Allow
Block
Letters / Other Materials By Post*
Please select an option
Allow
Block
Where did you hear about us?*
Please select an option
Access Point email
Access Point phone call
Adult Social Care
Amaze
Carers Centre Event
Carers Hub Website
Crossroads
Friend/Family
GP
Hospital Carer Link Workers
Hospital Staff
Hospital Poster
MAS
Mental Health Professional
Other Poster/Leaflet
QR Code
Other
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