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Is this a self-registration or a referral on behalf of a carer?*
Name of referrer (if you are making a self-referral please type n/a here)*
Referrers Contact Details (please enter a telephone number or email address. If you are making a self-referral, please type n/a here)*
What is your relationship to the carer?
What is the reason for your referral?*
Consent
NEWCIS stores limited personal information in compliance with the General Data Protection Regulations for the purpose in which you have engaged with our organisation. NEWCIS will only use your personal data following discussions with you, at your request and with your informed consent. We will never sell or give your data to third parties or act in a way that we believe will contravene the original reason you contacted us. You can request our privacy policy at any time.
I consent to NEWCIS securely storing my information in line with GDPR
If you are an organisation, please tick to confirm that you are GDPR compliant and have sought the persons permission to make the referral.
If you are a family/friend please ensure you have sought the persons permission to make the referral
Details of the carer
Address line 1*
Address line 2
Town*
Postcode*
County*
Title*
First name*
Surname*
Gender*
Date of Birth
Carer's email address
Carer's telephone number*
Alternative number (e.g. mobile number)
Ethnicity
What is your preferred language?*
Whilst we endeavour to provide you with our service, please note that we may need to get a translator if your language is not English or Welsh. This may delay our contact with you.
Do you, the carer, have any disabilities?
What is the main condition/disability of the person you care for?
'Are You Aware of any issues, current or historic, which could pose a risk to staff when lone working or group situations? E.g. Environmental Risk (access to property, hazards in/around property), Risk to Self (safeguarding issues), Risk to Others (history of verbal / physical aggression, pets at the property) *
Would you like to receive our quarterly newsletter?*
If you have an email address (which you have provided on this form) please consider opting to recieve our newsletter via email to reduce our resource and postage costs.
Details of the person you care for
Title
First name
Surname
Postcode
Main condition or disability*
Is the cared for person currently in hospital? If yes, please provide the name of the Hospital.
Why you are referring to or registering with NEWCIS? Please provide as much detail as possible to ensure the referral/registration is allocated accordingly.*