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Carers Identification Form

CARERS IDENTIFICATION AND REFERRAL 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

 

Date of Birth

 

Address

 

 

 

Post Code

 

Telephone Number

 


Care You Provide

 

 

 

 

DETAILS OF THE PERSON YOU LOOK AFTER:

Name

 

Date of Birth

 

Address

(If Different From Above)

 

 

 

Post Code

 

Telephone Number

 

GP Details

(If Different From Your Own)

 

 

 

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

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.


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