Referral Form for Carers Assessment

SECTION 1: These first set of questions are about the carer you are referring to us and their caring role.

Carer's First Name(s)

Carer's Surname

Carer's Home Address & Postcode

Carer's Telephone (landline & mobile)

Carer's Email Address. Please note that if you do not provide the carer's email address we will be unable to send our Carers News! which provides updates about our services, activities and relevant carer related news. Carers can unsubscribe at any time.

Carer's Date of Birth (DD/MM/YYYY)

Does the individual have any accessibility needs or require any support to access our services?

How long has the individual been caring for in the current caring role
---12 months or lessMore than 1 yearUnknown

SECTION 2: These questions are about the person being cared for.

Cared-for person's First Name

Cared-for person's Surname

What is the cared-for person's primary (main) condition or disability?
---Physical DisabilityCancerVisual ImpairmentHearing ImpairmentDual Sensory ImpairmentMental Health ConditionLearning DisabilityAustism or Aspergers SyndromeDementia or Memory & Cognition ConditionsFrailtySubstance Misuse or AddictionOther

Cared-for person's date of birth (DD/MM/YYYY)

What is the relationship of the carer to the cared-for person? The carer is the:
---Spouse or PartnerParent of an adult childParent of a child under 18 years oldSon or DaughterAny other relativeFriend or neighbourUnknown

Does the person being cared-for have a case open with with Adult Social Care?
---YesNoUnsure

If you are referring an individual who cares for more than one person please provide details in the box below

Please tell us about the carer's situation and what support needs you think they have?

Is this an urgent referral? Please note for all urgent referrals you will be required to have a telephone conversation with one of our Triage Carer Advisors following the submission of this form. Please contact us on 0114 272 8362. For information around urgent referrals see our assessment referral guidance for professionals
---YesNo

Please confirm the carer has consented to you passing on information in this form for the purpose of this referral.
---YesNo

SECTION 3: The next set of questions are about you as the referring professional.

Your First Name(s)

Your Surname

Your Organisation and Team

Your Job Title

Your Telephone (landline & mobile)

Your Email Address

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