Please note: There will be a waiting list for any new referrals made from Wednesday 14th March 2012, which will be reviewed on the Week Commencing Monday 9th April 2012

Adult Referral Form

Read the guidelines for referrers before completing this form Please Note: Hartlepool Carers Centre believe that all Carers who use the services we provide should have access to the information written about them, including this form. If you wish to share information that is confidential to the agency only and should not be shared with the Carer then please send this in a separate email to: lisa.cartwright@hartlepoolcarers.org.uk

ALL SECTIONS OF THIS FORM MUST BE COMPLETED OR THE APPLICATION WILL BE REJECTED

• Referrer Information
• Name:
• Date:
• Agency or relationship to the Carer:
• Address:
• Postcode:
• Telephone No:
• When are the best times for you to be contacted:
• E-mail:
• How did you find out about our service?:
• Information about the Carer you are referring to us
• Name:
• Date of birth:
• Age at date of referral:
• Gender:
• Address:
• Postcode:
• Telephone No:
• Cultural / Religion information:
• Ethnic Origin:
• Language:
• Referrals will only be accepted if the Carer is aware that you are making a referral to us. Please confirm this by ticking this box:
• Has a Carers Assessment been completed?: Yes No
• Are they the main Carer in the household?: Yes No
• How much time is dedicated to Caring each day?:
• Do they care for more than one person?: Yes No
• Relationship/s to the person they care for?
• For what reasons do they provide care and support - please provide details in this section:
• Do they provide care and support for any of the following: Chronic or severe ill-health? Mental health problems? Disability (physical, sensory or learning)? Drug and or alcohol problems?
• Does the Carer have significant difficulties with regard to any of the following areas: Housing Isolation Family Breakdown Relationship Finances Self-esteem and Confidence Mental Health Physical Health Training and or Employement
• Please summarise the Carer's current situation, the roles that they undertake and the circumstances of the person or persons they care for:
• Name(s) of the person(s) being cared for:
• Please provide the name and contact details of any other agencies working with the carer:
• Please provide the name and contact details of any agency working with the cared for person:
• Risk Assessment
• Please identify any risks that may be associated with making visits to the home environment.
• Referrers Name Confirmation:
• Please enter the code below in order to submit the form. (Cookies must be enabled on your computer)

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