Surrey GP Carers Prescription

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

Yes

First Name *

Last Name *

Sex of Patient *

Contact Telephone Number *

email address

Preferred method of communication *

Patient (Carer) Address *

Are there any other carers in the household? (details of other carers will be picked up as part of the assessment process)

Yes

Name of borough or district that carer lives in

Date of Birth *

NHS Number *

Referral Date *

Is the condition being cared for Dementia?

Yes

What is the primary condition being cared for?

Reason for Referral *

GP Practice Details

GP Practice Name *

GP Practice NHS Code *

Contact Telephone Number *

Name of Referring Practioner *

Position *

CCG Name *

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) Required	Call Back Required
Carers Information Pack	Type Of Service(s) Required	Call Back Required
Carers Emergency Card	Type Of Service(s) Required	Call Back Required
Carers Assessment (Social Services)	Type Of Service(s) Required	Call Back Required
GP Carers Break	Type Of Service(s) Required	Call Back Required
Local Carers Support Organisation (borough and district based 18+)	Type Of Service(s) Required	Call Back Required
Free on line resources (Carers email address needed)	Type Of Service(s) Required	Call Back Required
Crossroads Care Service (flexible home based care)	Type Of Service(s) Required	Call Back Required
Crossroads End of Life Carers Support Services	Type Of Service(s) Required	Call Back Required
Dementia Support	Type Of Service(s) Required	Call Back Required
Dementia Carers Support (Runnymede)	Type Of Service(s) Required	Call Back Required
TIHM for Dementia (The study is not suitable for people receiving end of life care)	Type Of Service(s) Required	Call Back Required
Surrey Young Carers (up to the age of 18)	Type Of Service(s) Required	Call Back Required
Military Carers Service	Type Of Service(s) Required	Call Back Required
Giving Carers a Voice	Type Of Service(s) Required	Call Back Required
Mencap Leisure Services (SERVICE SUSPENDED)	Type Of Service(s) Required	Call Back Required

Moving and Handling is a service where additional information will be needed

Moving and Handling

Reason for referring to Moving and Handling Service *

Other agencies involved

Social Services

Community Nursing Team

Physiotherapy

Other Other

Safety and Risk: Do you know of any reason why personal safety might be at risk when visiting the Carer?

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.

Date consent given *

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