Referral

Your details

Relationship to unpaid carer

I'm the unpaid carerFriend/familyProfessional

First name

Last name

Organisation

Job title

Contact number

Email address

How did you hear about us?

If you heard about us through a GP please give details

If other please give details

Please read the below statements and confirm the by ticking box below:

I confirm that the information provided is correct.
I confirm that I have consent from the persons mentioned on this referral to provide their information.
I understand that the information provided will be used for the purpose of providing appropriate services and support.
I confirm consent has been obtained for details to be shared with organisations stated in this referral.

Please see our privacy policy for more information.

Confirmation

I confirm by ticking this box that above statements are correct and true.

Keeping in touch

We'd love to keep you updated about our support services, events, and ways you can support Caring Together Charity if you wish to. This includes our monthly newsletter and magazine. If you've given us your details we may contact you by email or text in the future, unless you tell us not to below.

You can opt out now by ticking the box below, or at any time by clicking 'unsubscribe' in our emails or contacting us at fundraising@caringtogether.org.

For more details on how we use your information, please read our p rivacy policy .

Please do not contact me by email or text about similar charitable activities

Details of unpaid carer

Title

First name

Last name

Date of birth

Address

Postcode

Main telephone

Email address

Does the carer have a disability, illness or health issue of their own?

YesNo

Is the carer between 18 and 25 years old?

YesNo

Does the carer have any communication or other needs?

YesNo

Is the cared for person considered to be end of life? (please only tick yes if the cared for is palliative care / terminal illness)

YesNo

Please detail

Reasons for referral

Please briefly tell us about:

· The help or advice needed

· Any urgent concerns

· Any other organisations involved and providing support

· Anything else you think we should know at this stage

Details of cared for

Title

First name

Last name

Date of birth

Address

Postcode

Main telephone