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Surname*
Forename(s)*
Title*
Address line 1*
Address line 2
Address line 3
Address line 4 (Town)*
Address line 5 (County)
Postcode*
Main Telephone No.*
Mobile Telephone No.
Email Address (Main)
Date of Birth*
Ethnic Group*
Additional communication needs
GP Surgery*
Forename(s)
Title
Carer's relationship to dependant
Address line 1
Address line 4 (Town)
Postcode
Date of Birth
Ethnic Group
GP Surgery
Please state health condition, illness or disability*
Please state health condition, illness or disability
Personal Data Is Important To Us Northamptonshire Carers is registered with the Information Commissioner's Office and acts in accordance with the General Data Protection Regulations (GDPR, 2018). Under this legislation, your personal information will be treated as confidential, kept safe and secure, used fairly and lawfully and not kept for longer than is necessary. Declaration I understand that by registering my details with Northamptonshire Carers, a confidential computer record will be created. This will be kept securely as per the General Data Protection Regulations (GDPR, 2018). If I have provided any information about someone else (i.e. the person(s) I care for), I will ensure that they are advised about this. I understand that Northamptonshire Carers complete Carers Assessments on behalf of Northamptonshire County Council so Carers Assessments and Support Plans are shared securely between these organisations in order to deliver this statutory service. My information will only be shared with other parties with my consent. For example if I agree to be referred to other organisations to provide support. An exception to this would be if Northamptonshire Carers need to report a risk to myself or others whereby Northamptonshire Carers are duty-bound to follow safeguarding policies. If I have completed a Carers Assessment I agree that the information I have provided is accurate to the best of my knowledge. Copies of any Carers Assessment or Support Plan will be sent to me. I understand that I can also access a copy of my records held by Northamptonshire Carers. To request this or to discuss confidentiality further, I can contact Northamptonshire Carers' Data Protection Officer. Further information can be found on our website: https://www.northamptonshire-carers.org/privacy-policy
Please describe your situation and how we can help including what support or information you may need. . If you are a carer, this will form a light-touch Carers Assessment but you can also opt for a more in-depth one with a member of our team.*
If you are a carer, do you feel able and willing to continue in your caring role?
If you are a carer, would you want us to arrange a more in-depth Carers Assessment?
Are you happy to receive regular email bulletins from us?
Date of referral*
Are you a carer?*
If other or multiple services, please summarise:
Service being referred into*
How to say your name - e.g. Ian is EE-yun
Additional Organisation