Adult Carer Referral Form

All sections of this form MUST be completed in order for the carer to be registered with Blackpool Carers Centre. Thank you.

Return the completed forms to: Blackpool Carers Centre, Beaverbrooks House, 147 Newton Drive, Blackpool, FY3 8LZ or email: or fax to 01253 393450

FOR OFFICE USE ONLY
Name of Support Worker
Date of first assessment / contact with carer
Notes
Carer Name and Address
Title: / First Name: / Surname:
Address:
Postcode:
Carer Contact Details
Main Tel No. / Extra Tel No.
Emergency Contact Name: / Emergency Tel No.
Carers’ email:
Carer Personal Details
Gender: Male q Female q Transgender q Other q / Date of Birth: / /
Age: / Marital Status:
Sexual Orientation:
(Our funders require
this information) / Heterosexual q Gay q Lesbian q Bisexual q
Other q Please define:
Referrer Information
Referred by: / Organisation:
Job Title: / Contact No:
Signature: / Referral Date: / /
Consent Details
Sharing Information
In order to meet your needs, there may be occasions when we need to share information about you with other service providers.
If you wish this information not to be shared, please put a cross here:
Your personal information will be held and used in accordance with the Data Protection Act 1998.
Photo/Publicity Consent
We occasionally use photographs of carers in our magazine, website and other media, to highlight carers’ issues and raise awareness. If you do not wish to give consent for us to use your photograph, please put a cross here:
Carer’s Signature: / Date:
Carer GP Information
GP Surgery:
Is your GP aware of your caring role? (mark with X) / Yes: / No:
Ethnic Origin (mark with X)
Caribbean: / African: / Chinese: / Other Black: / Other White: / White British:
White European: / Indian: / Bangladeshi: / Other Asian: / Pakistani:
Mixed: / Other (please state):
Employment (mark with X)
Are you in employment? / Full Time: / Part Time: / Not at All:
Are you in education? / Full Time: / Part Time: / Not at All:
Details of the Person/People You Care For
(1) Name: / Date of Birth:
Address (if different from yours):
(2) Name: / Date of Birth:
Address (if different from yours):
What is their relationship to you?
(ie. Are they your, partner, child, parent, sibling, neighbour, friend etc):
(1) / (2)
How many hours a week do you spend caring for them? 1-19 q 20-49 q 50+l q
Cared For Person’s Health Information & Support Required (please use a separate sheet if necessary)
What health problems does the person/people you care for have?
eg. ABI, Cancer, COPD, Cystic Fibrosis, Dementia, Heart Disease, MS, Parkinsons, Stroke, Adult with Learning Disability, Physical Disability or Sensory Impairment, Adult with Mental Illness, Older Person 65+, Substance Misuse, Child with Disability or other additional needs (under 18)
Cared For Person’s GP Information
GP Surgery:
Is their GP aware they are being cared for? (mark with X) / Yes: / No:
Do YOU (the Carer) have a disability or any health problems of any kind? If so, please describe them as fully as possible: (For example, you may have a bad back or you may feel under stress)
What support do YOU (the Carer) need at this present time?
People in the Household
How many people, including yourself and children, live at the above address?:
Do any of them help care for the person/people being cared for?
(eg. children who are caring, partner etc) (mark with X) / Yes: / No:
If Yes, please request their agreement before giving their details below:
(1) Name: / Date of Birth:
(2) Name: / Date of Birth:
Further Details
Has the person you care for had a Social Care Assessment? / Yes: / No: / Don’t Know:
Has the person you care for had an Assessment with a
mental health team? / Yes: / No: / Don’t Know:
Have YOU (the carer) had a formal (statutory) Carer Assessment?
(mark with X) / Yes: / No: / Don’t Know:
Date of your last Carers’ Assessment (if applicable)
Would you like to be added to Blackpool Carers Centre’s database and
receive our magazine and other relevant information? (mark with X) / Yes: / No:
How would you like to receive our magazine? / By post q By email q
How did you hear about Blackpool Carers Centre?:
‘Keeping Carers Warm’ Project
Blackpool Carers Centre has a worker who is responsible for helping carers and their families make changes that may reduce their household outgoings. This project specifically addresses the cost of gas and electric in households (where the total cost of gas and electric is more than 10% of the household income). If this is the case in your household, would you like some advice around how to reduce your bills? / Yes: / No:

Please send the completed form to the address at the top of the first page.