Self-refer to The Carers Centre for Brighton and Hove

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

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

Town

County

Postcode

Their Date of Birth*

Their GP surgery

Their Gender*

Their Gender, if they prefer to self-describe

Preferred Pronouns

Preferred Pronouns - Prefer to Self-Describe

Please select the main condition for which this person receives support*

Please note any additional health conditions you’d like us
to 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

Add additional cared-for

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 contacting
info@carershub.co.uk*

GDPR preferences
Please 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?*