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Self Refer
If you are an adult, supporting someone over 18, and would like to access support from The Carers Centre for Brighton and Hove, please complete this self-referral form. The fields marked with an asterisk are required.
For professional referrals and young carer referrals please click on the links to be directed to the correct page.
Carer Details
Today’s Date*
Your Surname*
Your First Name*
Your Address, line 1*
Your Address, line 2
Town
County
Postcode*
Date of Birth*
Main Telephone No.*
Your Email Address
Do you have access to the internet?*
Your GP Surgery
Your Gender
Gender, if you would prefer to self-describe
Ethnicity*
Sexual Orientation
Sexual Orientation - Prefer to Self-Describe
Preferred Pronouns
Preferred Pronouns - Prefer to Self-Describe
Employment Status
Do you need an interpreter and/or translated materials?
Preferred Language (if not English)
Do you have any other communication needs? (No voicemails, large print, etc.)
Please select the main reason for which the person you care for needs your support
Do you have any health conditions or additional needs yourself you would like us to be aware of?
Cared-for Details
Their Surname*
Their First Name*
Please state their relationship to you*
Their Address – if different to yours, line 1
Their Address, line 2
Postcode
Their Date of Birth*
Their GP surgery
Their Gender*
Their Gender, if they prefer to self-describe
Please select the main condition for which this person receives support*
Please note any additional health conditions you’d like usto be aware of, or, if ‘other’ selected from dropdown, please describe.
Is the person you care for receiving support from any other services?
If yes, please give a brief description of services’ involvement
About your caring role
Please use this space to describe your caring role and any support for yourself which may be of interest
Are you aware of any reason our staff should not conduct a home visit? If yes, please give details*
Are there any other risks or safeguarding issues we should be aware of? If yes, please give details
Consent Given
In order to proceed with your referral, The Carers Centre will add the details provided above to our database. We will only use the data supplied to provide you with information and signpost you to relevant services. You and the person you support can withdraw consent at any time by contactinginfo@carershub.co.uk*
GDPR preferencesPlease be aware that choosing ‘block’ to any of these options may delay the processing of your referral.
Contact Preferences
Telephone*
E-Mail*
Text Messages*
Letters / Other Materials By Post*
Where did you hear about us?*