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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 Contact Details

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Personal Information

Are you, the carer, from a current or former military or veteran household *
Is there a young carer in the family (a child up to the age of 18. If there is we may be able to help them as well} *
Is there a young Adult carer in the family (a young person ages 18 to 24. If there is we may be able to help them as well} *
Have you had a Carers Assessment from Surrey County Council *

Information about the person(s) you are looking after

Please give details
 Relationship to CarerDisability(s)Ethnicity (optional)
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Age Range of peron(s) you are looking after
Are there any other agencies involved such as social services etc?

Is there anything elses we need to know about?

Consent

I confirm my consent for Action for Carers Surrey to hold and store my information contained on this form.
I confirm that if I have provided an email address that I am happy to be contacted by email.
Cared for information: Have you obtained the consent from the person(s) you are looking after for Action for Carers Surrey to hold the information contained about them on this form? (note If you are looking after a child consent may be given by the parent or gardian} *
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