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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?
Carer Details
Date of referral:
Title
First Names(s)*
Surname*
Address line 1*
Address line 2
Town*
Postcode*
Main Telephone*
Mobile
Email Address
Date of Birth*
Gender*
Sexual Orientation
Ethnicity
Religious Group
Marital Status
Employment Status
GP Surgery
Known to GP as Carer?
Approximately when did the caring role begin?
On a scale of 1-5 how stressed or anxious are you/is the carer about the caring situation?*
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?*
Cared For Details (optional)
First Names(s)
Surname
Address line 1
Town
Postcode
Date of Birth
Diagnosis/health condition
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.*