Home

1. Title, eg Mr, Mrs, Ms

3. Address, including postcode:

6. Mobile telephone:

8. What is your first language:

9. Do you require an interpreter?

yes

10. Are you in receipt of any benefits?

If yes, please give any details you have

11. Approximately how many hours of care do you provide each week?

0-19

20-49

50+

12. Do you have any medical conditions?

If yes, please give details

13. Please provide the name and address of your GP practice:

14. GP telephone number

15. Name of person you are caring for:

16. Address (if different to your own)

18. Health condition

19. What is their relationship to you? e.g. mother, son, friend

20. What would you like support with?

a) I would like information and advice on support available

b) I need some practical support, eg help in the home

c) I am struggling with my caring responsibilities and would like some help

d) My circumstances are changing and I would like some help, e.g I am returning to work, going into hospital, moving house etc.

e) The health of the person I am caring for has deteriorated and I would like support

f) Other

21. If you have ticked "other" please provide some details:

22. Is there anything else you would like to tell us about your caring role?

23. It would help us to ensure we are providing relevant services to all carers if you are able to answer the following questions. Please leave blank if you prefer not to say:

Religious beliefs

25.

Working status, eg works full time/part time; registered unemployed; not working; retired etc

27.

Sexual orientation, eg heterosexual or straight, gay, lesbian, bi sexual

28. How did you hear about us?

29. Data Protection Act 1998. Please note that the information you have given us is entered onto our in-house database and will not be passed onto anyone else without your permission.

I agree

You can contact us on the following phone numbers:

If you look after someone and would like to find out more information about Carers FIRST please contact us at:

Tel: 0300 303 1555

Email: hello@CarersFIRST.org.uk

If you are a professional and would like to refer a carer to Carers FIRST for support please contact us at:

Tel: 0300 303 1555 (option 2)

Email: referral@CarersFIRST.org.uk

ZZ - do not use Adult Self Referral Form

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