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)*

If you are making a referral on behalf of someone else, what is your relationship to the carer?

Select the reason for your referral. Please provide us with a brief description of your caring role and the reason you are registering / referring to NEWCIS at the bottom of this form.*

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.

Please input todays date below to indicate your consent.*

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?*

Are you / is the carer an asylum seeker?

Does the carer have any disabilities/health conditions? If multiple, please select the primary condition.

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.

Title

First name

Surname

Postcode

County*

Does the cared for live with the carer?

Date of Birth

Why you are referring to or registering with NEWCIS? Please provide as much detail as possible to ensure the referral/registration is allocated accordingly. If you are requesting a What Matters Conversation (Carer Needs Assessment) please tell us why you are requesting one.  Please note – if there is insufficient information submitted on the form, it may be rejected and sent back to you.*