Worcestershire Integrated Carers Hub (WICH)

Supported by Worcestershire County Council and three Clinical

Commissioning Groups

REFERRAL FORM
I agree that Worcestershire Association of Carers may hold confidential information about me and can exchange this on a ‘need to know’ basis, with other agencies that may assist me, including, but not limited to: Voluntary Organisations, Health and Social Care Professionals. / Yes/No / Carer Signature & Date
(if applicable) / For Office
Use Only
Are there any risks we need to consider regarding this referral
Has a Carers Assessment been completed? / Yes/No/Referred/Unknown
Has a Combined Assessment been completed? / Yes/No/Referred/Unknown
Date of Assessment (Carers/Combined) / Assessment completed by
(Carers/Combined)
Are you the main Carer? / Yes/No
Are you able to speak freely about your caring role / Yes/No
Are you happy for us to leave a message / Yes/No
ABOUT THE CARER
Name & Title / For Office Use Only
CCA1&2
Email / CCA 7
Telephone & Mobile Number / CCA6
Address / CCA3
Postcode / CCA4
Preferred Method of Communication
Preferred Times of Communication
Are there any communication difficulties
Date of Birth / CCA5
GP Name & Surgery
Illness/Disability
Employment Status
If employed how many hours a week
Hours a week caring
Ethnicity
Relationship to Cared For
CARED FOR INFORMATION
Has the cared for consented to sharing their information / Yes/No / For Office Use Only
CCA13
Name & Title / CCA8 & 9
Address (if different from Carer) / CCA10
Postcode
Telephone/Mobile (if different from Carer) / CCA12
Date of Birth / CCA11
Ethnicity
GP Name & Surgery
Illness & disability
Is this a life limiting illness?
What is the prognosis of the illness?
(Refer to WAC EOL Pathway) / Yes/No
Are you happy to have your needs considered together? / Yes/No / CCA14
Additional Information about the carer
What are your outstanding support needs?
(e.g. Training/Emergency Planning/Peer Support/Telephone Be-friending)
Reason for referral:
If a Carers Assessment has been completed, what are the outcomes?
What other support services are you in contact with?
What are they helping you with?
What Carer Services are in place or have you accessed in the past? / For Office Use Only
LEVEL SELECTION - LOW LEVEL OR MEDIUM/HIGH (following information will determine carer pathway journey
REFERRERS DETAILS
Name & Title / Organisation
Telephone Number
Email Address
Referral Date
PLEASE EMAIL COMPLETED REFERRAL FORM TO: whcnhs OR FAX 01905 457121

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