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Carer Details
Carers Title*
Carers Forename*
Carers Surname*
Carers Address Line 1*
Carers Address Line 2
Carers Address Line 3
Carers Town*
Carers County*
Carers Post Code*
Carers Mobile Number*
Carers Landline Number
Carers Email Address
Carers DOB*
Carers Gender*
Carers Ethnic Group*
Forename of Person Cared For*
Surname of Person Cared For*
Main disability / condition of person cared for *
Cared for Relationship to Carer*
How does the Carer support the cared for*
Please tick only one of the following questions that best describes the current situation.
Is the carer managing, but would like to be registered and receive a welcome pack?
Is the carer starting to struggle and would benefit from information, advice and an appointment?
Is the carer struggling to cope, overwhelmed or at breaking point and needs immediate intervention?
Is it clear that the carer’s mental health is not impacted by their caring role?
Will the carer benefit from accessing peer support / training / wellbeing sessions?
Will the carer require support to access group sessions?
Are there signs that the carer’s emotional wellbeing is impacted by their caring role?
Is the carer struggling to manage challenging behaviour from the person they care for?
Does the carer have a support network round them?
Is the carer lonely and / or isolated?
Is the carer struggling to juggle work and caring?
Are there signs that the carer's mental health and / or physical health is significantly impacted by their caring role?
Has the carer indicated self'harm or suicidal ideation?
Is the carer in the statutory safeguarding process and advocacy support is required?
Does the carer have urgent financial issues - e.g. loss of income, financial crisis?
Is the carer caring for someone at end of life or is concerned about hospital discharge and needs support?
Does the cared for currently have, or has had any Crisis Team intervention, or support from a Social Worker in relation to their mental health?
Contact Information
Is it safe to visit alone?*
Has the carer consented to referral?*
Can we telephone carer?*
Can we leave a voicemail?*
Can we send a text?*
Can we leave a message if someone else answers?*
Can we send an email?*
Can we send a letter?*
Referrer Details
Name of Referrer*
Referrers Address Line 1*
Referrers Address Line 2
Referrers Town*
Referrers County*
Referrers Postcode*
Referrers Organisation*
Type of referrer*
Referrers Role*
Referrers Telephone Number*
Referrers Email Address*