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Gateshead Carers Association
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External Referral
Referrer Details
Forename
(required)
This field is required
Surname
(required)
This field is required
Contact Number (Telephone/Mobile)
(required)
This field is required
Email Address
(required)
Please enter your email address
Please enter a valid email address
Organisation
(required)
This field is required
Department / Team
Is the cared for person of this carer living in Gateshead?
(required)
Yes
No
Has verbal or written permission been given by the carer to make a referral to Gateshead Carers?
(required)
Yes
No
How did you hear about us?
-- Please Select --
Leaflet
Events
Social Media
Word of mouth
Carer Details
Forename
(required)
This field is required
Surname
(required)
This field is required
Address
(required)
This field is required
Postcode
(required)
This field is required
Area (Town)
Contact Number (Telephone/Mobile)
(required)
This field is required
Email Address (if used regularly)
Preferred Contact Method
(required)
Please tick a checkbox
Landline
Mobile
Text Message
Email
Letter
Other
If ’Other’ (please state)
Gender Identity
(required)
This field is required
Date of Birth
(required)
Please select a date
Main Disability
Employed?
(required)
Yes
No
Retired
Has the Carer’s employment been affected by their caring role?
-- Please Select --
Yes - Had to leave job.
Yes - Had to reduce hours.
Yes - Had to give up on promotion opportunities.
No
GP Surgery
(required)
This field is required
Does the Carer’s GP know that they are a carer?
Yes
No
Don’t Know
Is the Carer a veteran?
(required)
Yes
No
Don’t Know
Is the Cared for a veteran?
(required)
Yes
No
Don’t Know
Main Language
(required)
This field is required
Interpreter Required?
(required)
Yes
No
Ethnicity
-- Please Select --
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish traveller
Mixed / multiple ethnic groups - White and Black Caribbean
Mixed / Multiple ethnic groups - White and Black African
Asian / Asian British - Indian
Asian / Asian British - Pakistani
Asian / Asian British - Bangladeshi
Asian / Asian British - Chinese
Black / African / Caribbean / Black British - African
Black / African / Caribbean / Black British - Caribbean
Other ethnic group - Arab
Other ethnic group (please specify)
Religious Group
-- Please Select --
None
Christianity
Buddhism
Paganism
Islam
Sikhism
Hinduism
Judaism
Do not wish to disclose
Other
Other religious group (please specify)
Sexual Orientation
-- Please Select --
Heterosexual
Gay
Lesbian
Bisexual
Transgender
Do not wish to disclose
Other
Other sexual orientation (please specify)
Cared For Person / Dependent’s Details
Forename
(required)
This field is required
Surname
(required)
This field is required
Does the Dependent live with the Carer?
(required)
Yes
No
If the Dependent does NOT live with the Carer, what is their address?
If the Dependent does NOT live with the Carer, what is their postcode?
Relationship to Carer
(required)
Please select a value
-- Please Select --
Child
Parent
Sibling
Partner / Husband / Wife
Niece/Nephew
Aunt/Uncle
Grandparent
Grandchild
Friend
Mother / Father in law
Son / Daughter in law
Step Father / Mother
Step Son / Daughter
Step Brother / Daughter
Other
If ’Other’ please specify
Date of Birth
Gender Identity
Main Disability
(required)
This field is required
How many hours per week does the Carer spend caring for the Dependent?
-- Please Select --
0 - 15 Hours
15 - 30 Hours
30 - 60 Hours
60+ Hours
If the Carer is Caring for multiple people, please provide us with the details of the other people they care for.
Referral Details
Did you identify any potential risks to our staff during your assessment ?
(required)
Yes
No
If ’Yes’ please outline
Is the Carer being supported by any other organisations?
(required)
Yes
No
Don’t know
If ’Yes’ please outline
Please tell us a brief description of the caring role and what support the carer is looking for.
(required)
This field is required
Referral Reason
(required)
Please tick a checkbox
Mental Health
Sleep
Self-esteem / Confidence
Coping Mechanisms
Excessive / Inappropriate caring roles
Short breaks from caring role
Achieving goals?
Nutrition, smoking, drinking
Healthy eating
Exercise
Attending appointments?
Maintaining relationships
Social inclusion - involvement with friends, family, local community
Education
Training
Employment
Volunteering
Hobbies / Interests
Achieving goals
Budgeting
Debt
Benefits
GDPR Consent
Please read the following statements fully and tick the boxes if the carer you are referring consents to the following.
I consent to having the details I have given on this form to be held securely on the Gateshead Carers database.
I consent to Gateshead Carers retaining personal details and copies of documents related to my support for as long as it remains relevant to the support I receive.
I consent to Gateshead Carers contacting me by phone.
I understand that my preferred method of communication will be used as the main way of keeping me updated and sending out the regular e-newsletter and events calendar. I consent to my contact details being used in this way.
I understand that my information will not be shared outside of the organisation without my knowledge or consent. Except in circumstances of safeguarding where it is necessary to ensure the safety of those involved.
I understand that I can remove my consent at any time and my personal details will be removed from the Gateshead Carers database except if legally required to do so. i.e because it is required under financial regulations if you have been paid a grant.
I understand that I can ask to see my personal details held by Gateshead Carers at any time.
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