GP Carer's 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 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)

IMPORTANT PLEASE READ THE FOLLOWING STATEMENT TO THE CARERS OR THE YOUNG CARER

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
*

Carer agreed they would like a GP carer’s prescription

Carer did not agree to a GP's carers prescription

If the Carer does not want a GP prescription or you have not ticked the box to confirm you have given the Carer a Fair Processing Notice, 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 recieved a copy of the Fair Processing Notice *

Yes

No

Please click here to download a copy of the Fair Processing Leaflet

Carer's Details

Carer's First Name *

Carer's Last Name *

Sex of Carer

Contact Telephone Number *

email address

Preferred method of communication

Date of Birth *

NHS Number *

Carer Address *

Referral Date *

What is the primary condition the carer is caring for? *

Please tick here if the Carer is caring for someone in end of life circumstances

Yes

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

Yes

Reason for Referral

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.

Yes

No

Are you referring a young carer

Yes

No

Is the young carer Gillick Competent?

Yes

No

Do the family wish to have a service

Yes

No

GP Practice Details

GP Practice Name *

GP Practice NHS Code *

Contact Telephone Number *

Name of Referring Practioner *

Position *

CCG Area *

email address *

Carer's Prescription (Type of Service Needed)

Type of Service (s) requested

	Tick the item(s) below
Carer's Information Pack	Tick the item(s) below
Adult Carer's Support	Tick the item(s) below
Young Carer's Support	Tick the item(s) below
GP Carer Break	Tick the item(s) below

Other information

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