Self Referral

About You

Your first name (required)

Your last name (required)

Date of birth (required)

Your Gender (required)
—Please choose an option—Woman (including trans woman)Man (including trans man)Non-binaryPrefer not to sayIn another way

Is your gender identity the same as the gender your were assigned at birth?
YesNoPrefer not to say

Sexual orientation (required)
—Please choose an option—HeterosexualGay or LesbianBisexualUnsurePrefer not to sayPrefer to Self-Describe

Preferred pronouns (e.g. she/her/hers)

Ethnicity (required)
—Please choose an option—ArabicAsian/Asian British – BangladeshiAsian/Asian British – ChineseAsian/Asian British – IndianAsian/Asian British – PakistaniAsian/Asian British – Any Other Asian BackgroundBlack/Black British – AfricanBlack/Black British – CaribbeanBlack/Black British – Any Other Black/African/Caribbean BackgroundMixed/Multiple Ethnic Groups – White & AsianMixed/Multiple Ethnic Groups – White & Black AfricanMixed/Multiple Ethnic Groups – White & Black CaribbeanMixed/Multiple Ethnic Groups – Any Other Mixed/Multiple Ethnic BackgroundWhite – British/English/Welsh/Scottish/Northern IrishWhite – Traveller/Gypsy/RomanyWhite – IrishWhite – Other White BackgroundPrefer Not To SayPrefer to Self-Describe

Employment status (required)
—Please choose an option—Not EmployedEmployed Full TimeEmployed Part TimeRetiredSelf-EmployedVolunteeringWish to Return to Work

Address including postcode (required)

If you have an unpaid caring role for someone over the age of 18 who has a long-term illness or disability, please complete the form below.

Your contact details

Landline

Mobile

Email address (required)

Is it ok to leave a message?
YesNo

Do you have any sensory or communication needs e.g. interpreting?
YesNo

If Yes, please say what needs you have

Have you had an assessment of your needs as a carer
(e.g. from the Council’s Access Point or a social worker)?
YesNoDon't know

About the person you are looking after

Their first name (required)

Their last name (required)

Their date of birth (required)

Their gender (required)
—Please choose an option—Woman (including trans woman)Man (including trans man)Non-binaryPrefer not to sayIn another way

Is their gender identity the same as the gender they were assigned at birth?
YesNoPrefer not to sayUnknown

Their sexual orientation (required)
—Please choose an option—HeterosexualGay or LesbianBisexualUnsurePrefer not to sayPrefer to Self-Describe

Their preferred pronouns (e.g. she/her/hers)

Their ethnicity (required)
—Please choose an option—ArabicAsian/Asian British – BangladeshiAsian/Asian British – ChineseAsian/Asian British – IndianAsian/Asian British – PakistaniAsian/Asian British – Any Other Asian BackgroundBlack/Black British – AfricanBlack/Black British – CaribbeanBlack/Black British – Any Other Black/African/Caribbean BackgroundMixed/Multiple Ethnic Groups – White & AsianMixed/Multiple Ethnic Groups – White & Black AfricanMixed/Multiple Ethnic Groups – White & Black CaribbeanMixed/Multiple Ethnic Groups – Any Other Mixed/Multiple Ethnic BackgroundWhite – British/English/Welsh/Scottish/Northern IrishWhite – Traveller/Gypsy/RomanyWhite – IrishWhite – Other White BackgroundPrefer Not To SayPrefer to Self-Describe

Their address, if different from yours

What is their relationship to you
e.g. are they your parent/partner/friend?

Please tell us their health condition and how it affects them

Their GP surgery

Are there any services or agencies involved
e.g. a care agency/Crossroads respite service?

How can we help you?

We provide a wide range of services and activities for carers.
All our services are free to carers.

Please tell us what sort of support might be helpful to you in your caring role:

Carers CardEmergency Back Up SchemeCarers ReablementMy Health MattersChanges Ahead – Support for Mental Health CarersEnd of Life/Life Limited SupportDementia SupportPeer SupportCarers Assessment ServiceSignposting/Referring to other ServicesBack care advice

Other – please tell us what else might help

Where did you hear about us? (required)
—Please choose an option—Access Point E-MailAccess Point TelephoneMessageAdult Social CareAlzheimer's SocietyAmazeCarers Hub WebsiteCrossroadsFriend/FamilyGPHospital StaffHospital PosterMASMental Health ProfessionalOther Poster/LeafletOther

Data Protection

In order to proceed with your referral, we will need to add your and the cared for person's details to our database. We will only use your and their personal information to provide you with information and signpost you to other services that relate to your caring role. You and the cared for person can change your mind at any time by contacting info@carershub.co.uk to remove your personal information from our database.
I Agree