ZZ - do not use Adult Self Referral Form
Carers FIRST is an independent, charitable organisation supporting and helping people who look after a relative or friend Please complete this form if you live in, or look after someone who lives in Kent, Medway, Lincolnshire, Waltham Forest, Haringey or Essex. Please provide us with as much information as possible and someone from our Carers Hub team will aim to contact you within 5 working days. If you require more urgent support please call us on 0300 303 1555. Thank you.
1 Title, eg Mr, Mrs, Ms
2 Full name:
3 Address, including postcode:
4 Date of birth:
5 Home telephone:
6 Mobile telephone:
7 Email address:
8 What is your first language:
9 Do you require an interpreter?
yes
no
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)
17 Date of birth
18 Health condition
19 What is their relationship to you? e.g. mother, son, friend
20 What would you like support with?
tick all that apply
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
24
Ethnicity
25
Working status, eg works full time/part time; registered unemployed; not working; retired etc
26
Marital status
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.
Please note that if you do not wish your details to be stored please do not submit this form, but call our Carers Hub on 0300 303 1555 where will be able to provide some limited support.
I agree