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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. Any fields marked with an asterisk * are mandatory.*
They care for:*
Referral Information
Referral Date*
Referrer Name & Organisation*
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.
Carer Details & Contact Information
Title*
Forename(s)*
Surname*
Date of Birth*
Address line 1 (Flat/House Number & Street)*
Address line 2
Address line 3
Address (Village/Town/City)*
Postcode*
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?
Email Address
Reason for Registration / Current Concerns
Briefly Summarise The Caring Situation*
Are there any services identified you would like us to discuss with the carer? (Only select those that apply)
Universal Services
Devon Carers Magazine
Peer Support
Hospital Services
Training to Care Safely
Benefits Check
Fire Safety Check
Targeted Support
Face to Face Training
Service Navigation
1:1 Support
Contingency Planning / Alert Card
Further Support
Carers Assessment
Replacement / Respite Care / Time for You - Sitting Service
For Hospital Service Referrals Only
Has this referral been prompted by a recent hospital admission?
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?
If yes, are we ok to ask the Young Carers team to contact you for more information?
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.