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 your Carer for a Carers Break Service. In this section please complete the details of the person you are referring

Young Carers
Please tick here where parental consent is required by your organisational policy . For more information please reference the Gillick Competency and Fraser Guidelines.
Parental Consent
Are there any other carers in the household? (details of other carers will be picked up as part of the assessment process) 
Is the condition being cared for Dementia?

GP Practice Details

Carers Prescription (Type of Service Needed)

When selecting the services you require you may wish to provide further sensitive / background information to the provider in which case tick the box or boxes requesting a call back.
Type Of Service(s) Required 
 Type Of Service(s) RequiredCall Back Required
Carers Information Pack
Carers Emergency Card
Carers Assessment (Social Services)
GP Carers Break
Local Carers Support Organisation (borough and district based 18+)
Free on line resources (Carers email address needed)
Crossroads Care Service (flexible home based care)
Crossroads End of Life Carers Support Services
Dementia Support
Dementia Carers Support (Runnymede)
TIHM for Dementia (The study is not suitable for people receiving end of life care)
Surrey Young Carers (up to the age of 18)
Military Carers Service
Giving Carers a Voice
Mencap Leisure Services (SERVICE SUSPENDED)
Moving and Handling is a service where additional information will be needed
Other agencies involved
Important Please Read This Statement to The Carer - Your personal information such as name, address and telephone number may be given to a 3rd party such as Carers Support or another agency.

Your NHS Provider will ensure that all personal data you provide in this form will be kept secure and processed only in accordance with the requirements of the Data Protection Act 1998.  Please contact your NHS Provider should you have any queries.
Surrey NHS and SILC logo