Newcastle Carers – Referral Form

PLEASE NOTE:

For a carer to receive services from Newcastle Carers, the person they look after must live in Newcastle. Seefor contact details of other carers organisations.

CARER’S DETAILS / REFERRER’S DETAILS
First name:
Last name: / First name:
Last name:
Job title:
Date of birth: / Service you work for:
Address: / Organisation you are employed by:
(E.g. Newcastle Hospitals Trust,
Newcastle City Council etc.)
Address:
Postcode:
Telephone number:
Email: / Postcode:
Can the carer be contacted by all of the following (please tick) / Mail
Phone
Email / Telephone number:
Email:
Special requirements(e.g. literacy support, interpreters required, health or accessibility needs): / Date:
CARED FOR PERSON’S DETAILS: / Name:
Date of birth (or age if unknown):
What is their illness / condition / disability? (Please detail)
CARER’S OWN HEALTH/ WELLBEING: / Is the carer in employment? (please tick)
Full time Part time Not employed Retired
Does the carer have an illness/condition / disability?
(Please detail) / Carer’s GP surgery:
Newcastle Carers will formally let their GP surgery know that they are a carer. Please tick to confirm consent has been given:
Brief details of caring situation and reason for referral:
WHAT WOULD THE CARER LIKE FROM NEWCASTLE CARERS?
Please tick:
Information pack only, including information about Contact to discuss their needs and the support
support groups, activities, training and other services. we can offer
For monitoring purposes, please tell us the carer’s:
Gender: Sexual orientation: Ethnicity:
Verbal consent has been obtained to refer the above carer, who is an unpaid carer, to Newcastle Carers and to add them to our confidential database.
Please tick to confirm consent has been given:
Can you confirm if there is any information known to you that indicates a risk inworking one-to-one with this person or making a visit at their home address? Newcastle CarersDOES NOT have access to Care First or RIO.
Please tick to indicate:
I do not know of any risks
Yes, there are risks (please provide details):

Signed:Date:

Newcastle Carers will contact the carer following referral. Please return this form to:-

Email: (preferred method)

Tel:(0191) 275 5060

SMS:07874 100043

Fax:(0191) 265 1191

Post:Newcastle Carers, 135-139 Shields Road, Newcastle upon Tyne, NE6 1DN

FOR COMPLETION BY NEWCASTLE CARERS ONLY
Carer contacted by (name of worker): / Date:
Level 1 provided - Information pack only Level 2
because (please state criteria met):
Appointment date and time: Appointment place:
Information pack given / sent: Yes / No / Date:
Additional information to be provided with info pack (please list):

1

Charity Registration No. 1145373 Company Registration No. 7869359