Referral to Carers Lewisham

REFERRAL TO CARERS LEWISHAM

CARER DETAILS

Where did you hear about Carers Lewisham?

Name: / Date of Birth:
Address: / Sex: F / M
Ethnicity:
Tel: /

Relationship to cared for person:

Email Address of carer: /

Your GP:

Is there anyone else in your home who helps with the caring? Yes No / Health of carer:
Other information (additional caring/childcare responsibilities, current circumstances):

Has a Carers Assessment been carried out: Yes No

CARED FOR DETAILS

Name: / Date of Birth:
Tel: / Sex: F / M
Address (if different from above): / GP:
Ethnicity: / Disability/Health problem:
How does the disability/illness affect them?

Has a Users Assessment been carried out Yes No

REASON/S FOR REFERRAL (please tick)
Go on CLs Mailing List / Counselling / Welfare Benefits
Newsletter/Info Pack / Young Carers / Emotional Support
Support Group / Dementia Carers / General support/advice
End of Life Carers / Working for Carers / Other:
FOR STATUTORY AGENCIES USE ONLY
Name of referrer: / Tel:
Agency: / Date of referral:
Do you have carer’s permission to refer? Yes No
CONSENT / Yes / No
I confirm my consent for Carers Lewisham to hold and process my personal details to produce anonymous monitoring reports for commissioners and funders
I give my consent to Carers Lewisham's employees and volunteers to access my data to be used to enable appropriate support to be identified for me and the person I care for
I give my permission for my personl details to be shared with other partners involved in the delivery of the service in accordance with the Data Protection Act
We will never communicate or divulge your information to any marketing/advertising agency
I understand I can withdraw my consent at any time by contacting or 020 8699 8686
I confirm that I am happy to be contacted by: Mobile phone □ Landline □ Email □ Post □
Carer name: / Date: / Signature:
RETURN FORM TO Lewisham Carers Centre
Address: Waldram Place, SE23 2LB / Email: / TEL: 020 8699 8686
FOR CL OFFICE USE ONLY
Date received: / Dealt with by:

Carers Lewisham, Waldram Place, Forest Hill, SE23 2LB

Registered Charity No: 1073592 Registered Limited Company No: 3681548