Name of referrer if applicable, (if referring yourself, please put "Self-Referral")*

Referrer Organisation/Role*

Referrer Contact Number*

Referrer Email Address

How did you hear about Derby Carers Information, Advice and Support Service?

Date of referral

Title

First name(s)*

Name*

Address line 1*

Address line 2

Town*

Postcode*

Main telephone*

Mobile

Email Address: This will allow us to keep you up to date with our services and latest carer activities, you can choose to unsubscribe at any time

Date of Birth*

Gender*

Sexual Orientation

Ethnicity

Employment Status

GP Surgery

Known to GP as Carer?

Do you/the carer have any health conditions?

Approximately when did the caring role begin?

Cared for Disability Category*

Please select from one of the following options for support:*

How would you like to receive your welcome pack?  (A welcome pack includes an information booklet detailing all the necessary support available to you as a carer and how to access our helpline should you need information, advice and guidance)*

Further details about you as a carer: What support could improve the caring situation? How is your health impacted by caring?  What are your communication preferences?*

Are there any risks identified we should know? (i.e. animals in property, no lone workers, communication needs, sensitivity towards cared for, etc.)*

Where does the main person being cared for live?*

Please tell us about the person you care for and their relationship to you. Are social care, other agencies or wider family/friends supporting?*

First name(s)

Name

Address line 1

Address line 2

Town

Postcode

Date of Birth

Derbyshire Carers Association collect and process your personal information in order to provide you with an appropriate and personal service. Most of the personal information we process is provided to us directly by you. Your information is securely stored on our database and will be permanently disposed of if consent is removed or as per our data retention policy. Your personal information will not be shared outside of Derbyshire Carers Association, without your permission. Personal information can be shared for safeguarding purposes when it's necessary to protect the safety and well-being of children or individuals at risk. Under the General Data Protection Regulation, the lawful basis we rely on for processing this information is consent. In consenting, you are confirming that information provided is true and accurate and that all referenced adults consent to the collection, processing, sharing and secure storage of information. By using our carers voice service, you consent to your feedback and anonymised quotations being used as examples by DCA and external services. You are able to remove your consent at any time. You can do this by contacting DCA on 01773833833 or emailing info@derbyshirecarers.co.uk for more information, please read our Data Policies. These can be found on the DCA website.*