Carers Identification Form
Do you look after someone who is ill, frail, disabled or mentally ill?
If so, you are a carer and we would like to support you. Please complete this form and hand it in to reception. If you agree, we will pass your details to the Carers Service, an organisation providing information and advice, local support services, newsletters and a telephone linkline for carers.
We will also refer you, with your permission, to have your needs assessed by Adult Care Services.
A carer’s assessment is a chance to talk about your needs as a carer and the possible ways help could be given. It can also look at the needs of the person you care for. This could be done separately, or together, depending on the situation. There is no charge for an assessment.
Your Details
Name
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Date of Birth
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Address
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Post Code
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Telephone Number
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Care You Provide
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Details of the person you look after
Name
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Date of Birth
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Address
(If Different From Above)
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Post Code
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Telephone Number
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GP Details
(If Different From Your Own)
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□ Please pass my details to the Carers Service
□ Please refer me to Adult Care Services for a Carers Assessment
Thank you for completing this form
Carers Identification Form
Privacy Protection
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be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
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Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.