referral form

Register with Harrow Carers

Please fill out our quick and easy registration form below

Are you the carer completing this registration?
(if a professional please go to our Google Document)

Is your caring role primary or secondary?

Section 1 – Carer Details

Relationship to Cared for

Title

Forename(s)*

Name*

Address*

Address line 2

Address line 3

Address line 4 (Town)*

Postcode*

Date of Birth*

Main Tel. No*

Mobile

Emergency Tel (We will use this number in case of an emergency.)*

Email Address

Ethnicity*

Religion*

Gender*

Sexuality*

Do you have any disabilities / Illnesses

If yes, please state your main disability

Registered GP Surgery

Average Hours Of Caring Per Week*

Employment Status

Would you like to receive our quarterly newsletter and news bulletins*

Would you like to sign up to our WhatsApp notification broadcast group?

How Did You Hear About Us?*

Section 2 - Cared for / Dependent

Title

Forename(s)*

Name*

Address*

Postcode*

Date of Birth*

Disability / Illness

Section 3 - Which Services would you be interested in?

Social Support groups/Community Hub/Outings, Events

Activity/exercise groups e.g., Yoga, Pilates, Qigong, Zumba, Archery, Badminton

Wellbeing courses: Mindfulness, Managing Stress & Anxiety, Sleep Management

Counselling 1-1

Information & Advice (including benefits: Attendance Allowance/Carers Allowance/DLA/PIP, Blue Badge)

Dementia Support Programme

Employment Support - Signposting

Macmillan Cancer Carer Support – Signposting

Befriender Programme

Young Carers 5 to 16 and Young Adult Carers 16 to 25

*Homecare Services (please note charges apply for this service)

*Homeshare (please note charges apply for this service)

Section 4 - How Are You Feeling?

Please tick the boxes below that best describe your experiences over the past 2 weeks. We will follow up with you via email or telephone after 13 weeks to check how you're feeling. This helps us assess whether our services have improved your wellbeing and supports our efforts to secure funding to continue providing assistance to you.

I've been feeling optimistic about the future*

I've been feeling useful*

I've been feeling relaxed*

I've been dealing with problems well*

I've been thinking clearly*

I've been feeling close to other people*

I've been able to make up my own mind about things*

In general, how would you say your physical health is?*

Are you aware of your rights to an assessment as an unpaid carer carried out by the local authority? Care Act 2014 AHAdults@harrow.gov.uk Telephone: 020 8901 2680.

Please confirm if you would like to be referred for a Carers Assessments by Harrow Council

Yes

No

Any information you provide will be handled in strict accordance with data protection laws. We do not share your personal data with third parties. Any data we collect is used in aggregate form and remains completely anonymous. This ensures that your identity is protected while helping us evaluate the impact of our services and secure the necessary funding to continue supporting you. If you have any questions or concerns about how your data is used, please don’t hesitate to contact us. By registering, you consent to us storing your details in our database. View our Privacy Policy.
We may occasionally request feedback and inform you of new activities. Thank you for registering with Harrow Carers.