Carer Self Referral Form 2025

Welcome to our Carer Registration form.

In the next few screens, we will be asking you for:
• your permission for us to store your data
• information that we need to know about you,
• how you would like us to contact you after we have processed your registration
• information that we need to know about the people you care for

It will take about 10 – 15 minutes for you to complete the Registration form. There a number of screens for you to go through - your registration will not be completed until you have pressed the submit button at the end of the last form.

What happens next:
After you have filled this form in, you will receive an automatic email that let you know that we have received your registration.
Our Carer Support team will review the information that you give and respond to you. Depending on the information that you give us in the form, this may be an automated email to let you know how to access our support or Carer Support Hub, or it may be an in person response via phone or email.

** If you need our immediate support, need to talk to someone now, or find yourself in a crisis in your caring role, please ring us on 01933 677907 and then select Option 2 . If all of our Carer Support members are on the phone, we will call you back as soon as we can **

Consent to store my information
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Please click here to read our privacy statement – https://www.northamptonshire-carers.org/privacy-policy
When you register with us as a Carer, we will store the details that you give us in our Northamptonshire Carers database. We take your data security and privacy very seriously and we are compliant with the Data Protection Act 2018 and The General Data Protection Regulations. You can withdraw your consent at any time by calling or emailing us to let us know. *
Date of consent to store personal data*
About you (The Carer)
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Date of referral
Are you a carer?
Referrer Type
Self
Family Member or Friend - carer has consented to me completing this self-registration on their behalf
Other - carer has consented for me to complete this self-registration on their behalf
Service being referred into
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?
My title
My first name*
My surname*
My preferred name
How to pronounce my name
My address (line 1)*
My address (line 2)
My address (line 4 Town)*
My address (line 3 County)*
My address (postcode)*
Local Authority I live in.
The phone number I would like you to contact me on*
An alternative contact number you can get me on (optional)
My email address
My date of birth*
Gender*
Sexual Orientation. If you do not wish to disclose this information, please record as ‘prefer not to say’*
My ethnic group. If you do not wish to disclose this information, please record as ‘prefer not to say’

*
Any additional communication needs that I have (large print, hard of hearing etc)
Do I require an interpreter?
Yes
No
If I need an interpreter, which language do I need?
Which GP surgery am I registered with?*
Do I consent to you sharing my Caring role with my GP? *
Do I have any long-term health conditions or disabilities that I would like to make you aware of?
How many hours (approximately) do I spend on my Caring role each week?*
What is my working status?
What is my accommodation status?
How can we help you?
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Please can you tell us about the Carer support you provide to the cared-for person. Please tick all the checkboxes that apply.
Personal care and support
Managing paperwork and finances
Shopping
Collecting or dispensing medication
Maintaining a habitable home
Supporting to stay safe
Arranging and attending appointments with the cared-for
Communication with others
Transport
Preparing Meals
Please tell us about the impact the caring role has on your own health, wellbeing and everyday life*
I would like support with the following (please select all that are appliable)
My caring role is impacting upon my own physical health
My caring role is impacting my own mental health
Emotional and Listening support
Respite or Replacement Care
Time for me
Family and Relationships Support
Financial/Benefits Support
Understanding the cared-for persons condition
End of Life/Palliative Care Support
Understanding Social Care and Health Processes
Housing Advice
Legal Advice
SEN Education Advice
Employment/Training Advice
Carer Support Groups
What would I like you to do when you process my registration?
I would like you to call me
I would like you to email me
I would like you to contact me via post
Registration only - I will use the online Carer Support Hub and will call you if I need anything else
About the people I care for
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What is their title?
What is their first name?*
What is their surname?*
What is their gender?*
What is their address (line 1)?*
What is their address (line 2)?
What is their address (line 4 - Town)?*
What is their address (line 5 - County)?*
Which Local Authority do they live in?*
What is their date of birth?*
GP Surgery*
What is their ethnic group?*
please provide details of any long-term health conditions or disabilities*
Add another Cared-For

Confirmation Email