Carers look after family, partners or friends in need of help because they are ill, frail or have a disability. The care they provide is unpaid.  Carers UK Definition

Carer Information

Please fill in this form to refer the Carer for a Carer's Prescription Service. In this section below please complete only the Carer's Details. Please record if the Carer declines (in which case no other further data is required)

IMPORTANT PLEASE READ THE FOLLOWING STATEMENT TO THE CARERS OR THE YOUNG CARER

The personal information you provide in this form will be shared with Surrey Independent Living Council and/or Action for Carers (Surrey). They will use the information to contact you to discuss the support and assistance they can provide to you via the Carer’s Prescription Service.
They will ensure that all personal information on this form is kept secure and processed only in accordance with current data protection legislation. You can contact them if you have any queries about how they use your personal information.

To enable us to count all carers who have been identified  (whether they consent or not to receiving a carers prescription): please tick one of the boxes below to confirm that consent has been obtained or declined to share carers information with Action for Carers Surrey
 *

Fair Processing Notice

I declare that the carer or the young carers family have recieved a copy of the Fair Processing Leaflet. *

Carer Details

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Please tick here if the Carer is caring for someone in end of life circumstances?
Are there any other Carers in the household (details of other carer's will be picked up as part of the Triage process)

Young Carer (5 to 18 years)

Are you referring a young carer
Please tick here if parental consent is required by your organisational policy . For more information please reference the Gillick Competency and Fraser Guidelines.
Do the family wish to have a service?

Providers Details

Carer's Prescription (Type of Service Needed)

Please tick the service(s) the Carer requires
Type of Service (s) requested 
 you must tick at least one item
Care Information Pack
Adult Carer Support
Moving & Handling Service
Young Carer's Support Service
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