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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 Details

Are you the carer from a current or former military or veteran household?
Is there a young carer in the family?
If you are over 25 Is there a young adult carer in the family (18 to 24)?
Have you, the carer had a Carers Assessment *

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
2nd Cared For
3rd Cared For
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 *


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 note that Email is the most cost-effective way for us to send you information. Please tick all that apply
Sharing Information: I consent to information about me being shared with other professionals or organisations to help provide me with support, where appropriate, either now or in the future. These may include but not exclusively: , Crossroads Care Surrey, Alzheimer’s Society, GPs and Health Professionals, Employers/Employment Service, Housing Providers, Colleges and Training Providers, or other relevant voluntary/charitable organisations. *
I consent to information being shared with Surrey County Council to enable, for example, a referral to be made for an assessment, or in connection with support for me and for the person I care for. *
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:
You can change your preferences at any time – by emailing ,   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   For further information please see our Privacy Policy at
Signature *