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

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?*

First Names(s)

Surname

Address line 1

Address line 2

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.*