Registration Form for Professionals

Please use this form to register an unpaid adult carer who cares for another adult that lives in the Devon County Council area. The person they support maybe ill, frail, disabled, have a mental health issue or substance misuse problem.

By completing this form and ticking the box below, you confirm that you have permission from the person named below and that they agree to their information being used to register them onto Devon Carers systems for the purpose of supporting them in their caring role. Information is shared with Devon County Council and the NHS as the service commissioners, to provide the carer with the best possible support.

Any fields marked with an asterisk * are mandatory.*

Carer Consent Obtained*

They care for:*

Referral Information

Referral Date*

Referrer Name & Organisation*

Organisation Type*

Referrer Email Address & Contact Number*

I am a Time For You provider and the carer has agreed to be registered specifically so that they can access the TFY service.

Yes

N/A

Carer Details & Contact Information

Title*

Forename(s)*

Surname*

Gender Identity

Date of Birth*

Address line 1 (Flat/House Number & Street)*

Address line 2

Address line 3

Address (Village/Town/City)*

Postcode*

Only provide contact information for the carer that we are able to use

What is the carers preferred method of contact?*

Are there any factors that will affect our ability to engage in conversation with the carer? Does the carer require additional support, i.e. enabler, translator, advocate etc.? Please specify

Landline Telephone number

Is it OK to leave a message on the landline number? (Without consent we are unable to leave messages)

Mobile Telephone Number

Is it OK to leave a message on the mobile number?

Yes

Email Address

Reason for Registration / Current Concerns

Briefly Summarise The Caring Situation*

Select from the drop-down list what you would like us to do*

If the person above is already known to Devon Carers, what would you like us to do?

For Hospital Service Referrals Only

Has this referral been prompted by a recent hospital admission?

Yes

Date of discharge or expected date of discharge

Which hospital & ward?

Identifying Young Carers

Are there any children who may have a caring role in the household?

Yes

If yes, are we ok to ask the Young Carers team to contact you for more information?

Yes

Thank you for referring this carer to Devon Carers. See https://devoncarers.org.uk/contact/ for more information on how the carer can get in touch should they wish to.