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 Derbyshire Carers Association?

Date of referral:

Title

First Names(s)*

Surname*

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.

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).*

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 Diagnosis/Health condition:*

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

Additional Information: E.G. How is health impacted by caring? Are social care, other agencies or wider family/friends supporting? What support could improve the caring situation?

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?*

First Names(s)

Surname

Address line 1

Address line 2

Town

Postcode

Date of Birth

Relationship to Carer/any additional information on the person being cared for:

Derbyshire Carers Association is registered with the Information Commissioner's Office and acts in accordance with the General Data Protection Regulation (GDPR, 2018). Under this legislation, personal information will be treated securely, used fairly and lawfully and not kept for longer than is necessary. I understand that the information I share will be stored in accordance with GDPR and a computer record will be created. I have the consent of the Carer I am referring. I agree to my details as the referrer (name, organisation, and contact details) to be stored securely by DCA. For more information, please visit www.derbyshirecarers.co.uk or call 01773 833833 to request copies of our data retention and sharing policies.*