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

Covid 19 Resources Last Updated 1st April 2020

Carer Information

Please fill in this form to refer the Carer for a Carer's Prescription Service. In the section below please complete only the Carer's Details. Please record if the Carer declines (in which case no further data is required)

The personal information you provide in this form will be shared with Surrey Independent Living Council and/or Action for Carers (Surrey). They will use the information to contact you to discuss the support and assistance they can provide to you via the Carer’s Prescription Service.
They will ensure that all personal information on this form is kept secure and processed only in accordance with current data protection legislation. You can contact them if you have any queries about how they use your personal information.
Please tick one of the boxes below to confirm that agreement has been obtained or declined to share carers information with Surrey independent Living Council and Action for Carers Surrey
If the Carer does not want a GP prescription we are unable to process the precription in accordance with current data protection legislation. PLEASE DO NOT SUBMIT THIS FORM IF YOU SEE THIS MESSAGE

Fair Processing Notice

I declare that the carer or the young carers family has received a copy of the Fair Processing Notice *

Carer's Details

Please tick here if the Carer is caring for someone in end of life circumstances
Are there any other Carers in the household (details of other carers will be picked up as part of the assessment process?

Young Carer's (5 to 18 years)

Please tick here if parental consent is required by your organisational policy . For more information please reference the Gillick Competency and Fraser Guidelines.
Are you referring a young carer
Is the young carer Gillick Competent?
Do the family wish to have a service

GP Practice Details

Carer's Prescription (Type of Service Needed)

As part of our COVID response, a series of FREE 45 minute webinars are available to carers The sessions will help carers in creating a ‘Safer Environment’ during the pandemic, with the aim of reducing infection rates. Please check the carer  has access to the internet on a device before ticking the COVID 19 box below. The internet access may be through home internet or mobile internet.

Type of Service (s) requested 🛈
 Tick the item(s) below
Carer's Information Pack
Adult Carer's Support
Young Carer's Support
GP Carer Break
NEW Service -to support carers during COVID19 SUCH