Carer Self Referral Form

Action For Carers (Surrey) is a county wide organisation providing support and advice to the thousands of Carers across Surrey who live within the county. Please complete this form if you feel we can help you. One of our Carers Information Centre Advisers will then contact you to see how we can be of service to you.

Carer Details

First Name *

Last Name *

Year of birth *

Sex

Male

Female

Carer Contact Number *

Carer email address

Carers Address *

Town *

County *

Postcode *

Ethnicity (optional)

Are you the carer from a current or former military or veteran household?

Yes

Is there a young carer in the family?

Yes

Is there a young adult carer in the family (18 to 24)?

Yes

GP Surgery

Have you, the carer had a Carers Assessment *

Yes

Not Sure

If you have had a Carers Assessment do you remember the date it took place? +

Have you, the Carer any disabilities or illness?

Do you have any language, religious or cultural considerations?

Do you have any specific communications needs, e.g large print, audio, translation etc?

Cared For(s)

In the course of supporting you, the personal data concerning the cared for person may need to be recorded in as far as it is required to support to provide services to you.

Please give details

	Age Range (U18/18-24/ 25-64/ 65-84/ 85+)	Disability
Main Cared For	Age Range (U18/18-24/ 25-64/ 65-84/ 85+)	Disability
2nd Cared For	Age Range (U18/18-24/ 25-64/ 65-84/ 85+)	Disability
3rd Cared For	Age Range (U18/18-24/ 25-64/ 65-84/ 85+)	Disability

Are there any other agencies involved such as social services, Mental Health Team, Crossorads Care, Dementia Support, GP or any other relevant agency?

Are there any other safety concerns for staff visiting at home? E.g. Does anyone in the home show dangerous behaviour/ known to be aggressive or violent? Anything else - remote location, dogs etc *

Yes

If yes please add details

Consent

Your information will be processed securely in line with current data protection legislation. Your personal information is kept for the purposes of providing, advice, information and support to you in your caring role. As a core part of our service we will send out newsletters, invitations to carer support groups, forums and other carer related events and activities, which we run. We also from time to time seek your views to help inform our service provision and compile anonymised statistical data and case studies for commissioning and research purposes.

Please let us know below how we may contact you. Please tick all that apply

Post

Telephone

Text

Sharing Information: If you are receiving a service from us, we may ask you to consent to information about you being shared with other professionals or organisations to help provide you with support, where appropriate, either now or in the future. We will ask you at the time if such a referral is deemed appropriate. These may include but not exclusively: GPs and Health Professionals, Employers/Employment Service, Housing Providers, Educational Establishments or Colleges, Training Providers, or other relevant voluntary/charitable organisations.

We may also ask your permission to share with Adult Social Care or Children’s services, to arrange, for example, a carer’s assessment.

We will not share information without your consent except where disclosure is necessary for safeguarding purposes or as required by law.

We also raise awareness of carer issues both locally and nationally and invite you to participate in consultations and campaigns to help improve services for carers. Yes – please send me information about the items I have ticked below:

Consultation and Campaigns on issues related to carers

Details of other Surrey wide and National Events / Activities

Action for Carers Fundraising activities or events

You can change your preferences at any time – by emailing dpo@actionforcarers.org.uk , phoning 01483 302748 or by post to FREEPOST, Action For Carers Surrey.

Where we choose to have certain services, such as IT or data processing, provided by consultants or contractors, we do so in accordance with current legislation and take all reasonable precautions regarding the practices employed by them to protect personal information.
You have a right to know what personal data Action for Carers (Surrey) holds about you. You also have the right to have your data corrected or deleted. Please address any such issues to us in writing to our Data Protection Officer at the registered address as detailed below or by phone to 01483 302748 or dpo@actionforcarers.org.uk For further information please see our Privacy Policy at www.actionforcarers.org.uk

Signature * 🛈

clear

Date Consent Given * +