External Referral

Forename (required)

Surname (required)

Contact Number (Telephone/Mobile) (required)

Email Address (required)

Organisation (required)

Department / Team

Is the cared for person of this carer living in Gateshead? (required)

YesNo

Has verbal or written permission been given by the carer to make a referral to Gateshead Carers? (required)

YesNo

How did you hear about us?

Forename (required)

Surname (required)

Address (required)

Postcode (required)

Area (Town)

Contact Number (Telephone/Mobile) (required)

Email Address (if used regularly)

Preferred Contact Method (required)

LandlineMobileText MessageEmailLetterOther

If ’Other’ (please state)

Gender Identity (required)

Date of Birth (required)

Main Disability

Employed? (required)

YesNoRetired

Has the Carer’s employment been affected by their caring role?

GP Surgery (required)

Does the Carer’s GP know that they are a carer?

YesNoDon’t Know

Is the Carer a veteran? (required)

YesNoDon’t Know

Is the Cared for a veteran? (required)

YesNoDon’t Know

Main Language (required)

Interpreter Required? (required)

YesNo

Ethnicity

Other ethnic group (please specify)

Religious Group

Other religious group (please specify)

Sexual Orientation

Other sexual orientation (please specify)

Forename (required)

Surname (required)

Does the Dependent live with the Carer? (required)

YesNo

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)

If ’Other’ please specify

Date of Birth

Gender Identity

Main Disability (required)

How many hours per week does the Carer spend caring for the Dependent?

If the Carer is Caring for multiple people, please provide us with the details of the other people they care for.

Did you identify any potential risks to our staff during your assessment ? (required)

YesNo

If ’Yes’ please outline

Is the Carer being supported by any other organisations? (required)

YesNoDon’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)

Referral Reason (required)

Mental HealthSleepSelf-esteem / ConfidenceCoping MechanismsExcessive / Inappropriate caring rolesShort breaks from caring roleAchieving goals?Nutrition, smoking, drinkingHealthy eatingExerciseAttending appointments?Maintaining relationshipsSocial inclusion - involvement with friends, family, local communityEducationTrainingEmploymentVolunteeringHobbies / InterestsAchieving goalsBudgetingDebtBenefits

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.

External Referral

Referrer Details

Carer Details

Cared For Person / Dependent’s Details

Referral Details

GDPR Consent