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Support for Carers in Calderdale Referral Form
If you care for a family member, friend or neighbour who cannot manage without support due to a health condition or disability you may benefit from support from our Carers Wellbeing Service.
We provide carers aged 18 and over with an extensive range of resources and support designed to promote your own health and wellbeing. Our team of professional carer support workers cover all of Calderdale and our workers will get to know you and your situation and tailor our services to give you the most relevant and appropriate support.
If you care for someone with a mental health condition you can receive specialist support from our Mental Health Carers Support Team.
How Can We Help You:
Title*
Date of Birth
Forename*
Surname*
Email
Main telephone
Mobile telephone
Contacts preferences: Phone, email, or post
Address line 1*
Address line 2
Address line 3
Address line 4 (Town)*
Address line 5 (County)*
Postcode*
GP Surgery*
Gender
Employment status?
Ethnicity
Sexual Orientation
Faith
Do you have a disability of your own?
Support Required
Illness or disability of person cared for
Main Referrer/Contact
Notes
First Referral Date
Confidentiality and Consent to DiscloseMaking Space holds personal information about you and keeps a record of all they do with you; this will be stored on paper or on the computer. You have a right to see the personal information we hold about you; please speak to a team member about this who will tell you what to do. All of your personal information is held confidentially in line with the Data Protection Act 1998.It is essential that Making Space share information with the person or agency that referred you to our service and is involved in your care or support. To do this we need your permission. If necessary, we may also share information with other agencies unless you requested us not to do so. Please let staff know who you do not wish to be contacted regarding your care or treatment.Employees and volunteers of Making Space will only share information on a ‘need to know’ basis when it is necessary and justified, in line with the confidentiality policy. This includes the necessary sharing of information where there is a risk of harm to yourself or others and if required to under law (e.g. criminal activity).