Carer's Prescription

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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
*

Consent Agreed

Consent declined

Fair Processing Notice

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

Yes

No

Fair Processing Leaflet will be sent to carer after referral

Please click here to download a copy of the Fair Procesing Leaflet

Carer Details

Carer's First Name *

Carer's Last Name *

Sex of Carer 🛈

Contact Telephone Number *

email address

Age of Carer *

Preferred method of communication

Carer Address

Name of GP Practice Carer is registered with

Referral Date * +

What is the primary condition the carer is caring for? *

Please tick here if the Carer is caring for someone in end of life circumstances?

Yes

Are there any other Carers in the household (details of other carer's will be picked up as part of the Triage process)

Yes

Reason for Referral 🛈

Has the carer or cared for ever worked within the military? *

Young Carer (5 to 18 years)

Are you referring a young carer

Yes

No

Please tick here if parental consent is required by your organisational policy . For more information please reference the Gillick Competency and Fraser Guidelines.

Yes

No

Do the family wish to have a service?

Yes

No

Providers Details

Organisational Name

If your organisation is not listed above please enter your organisation here

Name of Referring Practioner *

Position *

Contact Telephone Number *

Email Address *

Equalities Monitoring

What is the carers ethnic group? *

Other ethnic group - please specify

What is the carers religion? *

How does the carer self identify their sexual orientation? *

Carer's Prescription (Type of Service Needed)

As part of our COVID response, we have one distinct additional offer to carers:

NHS Carer Identification Letter (COVID 19) - This is a letter which is given to carers to identify them as a carer and to help them maintain their caring role in event of restriction of population movement by Government because of COVID 19 infection rates. The letter will be sent in hard copy or via email from Action for Carers (Surrey) when this form is processed.

Please tick the service(s) the Carer requires

Type of Service (s) requested 🛈

	you must tick at least one item
Carer Information Pack	you must tick at least one item
Adult Carer Support	you must tick at least one item
Moving & Handling Service	you must tick at least one item
Young Carer's Support Service	you must tick at least one item
Carers Flu Vaccination Voucher (Oct to March)	you must tick at least one item

Carer Breaks Services and Carer Emergency Care Planning Service

The following services are also open to Carers across the county:

Carer Replacement Breaks - It’s important that carers are able to take some time out of their caring role and have a short break. Crossroads hasa team of Carer Support Workers to deliver replacement breaks for loved ones, either at home or within the community. Carers are able to take advantage of a one off 35 hour of allocated breaks services.

Emergency Care Planning Service - By Carers registering with the service, they can nominate trusted contacts whom would be contacted to provide emergency support if the carer became ill or being admitted into hospital on an unplanned basis etc. If no one is available from the contacts, they are provided up to 48 hours’ round the clock care with fully-trained staff members to step in to provide care free of charge.

End of Life Carer Breaks - End of Life Carer breaks are available to carers caring for someone with a life-limiting illness. This breaks service that Crossroads Care provides is unlimited for carers to take a break in what is a extreamly difficult time

If you wish to refer the carer to one of these services please tick the relevant box(s)

Replacement Carer Break

Carers Contingency planning

End of Life Carer Breaks Service

Other Information

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Last Updated V10 May 2022