Register a Carer

It is important that we know if you are a carer so that we can make sure you receive information, services and the help that is available. If you are a carer please complete this form.

Carer Identification and Referral Form

If you are human, leave this field blank.

Section 1: Carer's Details

Title: * Title:

First Name *

Last Name *

Gender: *

Email Address: *

Telephone No.

Address *

Postcode: *

When did the caring role start? *

What is your ethnic origin? *

Please tick if interpreter is required

Preferred Language: *

Section 2: Cared for person's details

Title: * Title:

First Name *

Last Name *

Gender: *

Relationship to carer: *

Nature of disability/illness: *

Telephone No.

Postcode: *

Address *

Section 3: Reason for referral

Briefly state why the carer is being referred, e.g what support or information they are looking for/ what needs they have:

Anything else you’d like to tell us:

Section 4: Consent

We would like to pass your details onto your local adult or young carer support service, which provides information, advice and support to carers, including information about your rights, how you could access a break from your caring role, financial support, and support to access other services.
You will be contacted directly for further details about your caring role and the person you care for.

Yes, please pass my details onto my local Carers Support Service

No, please do not pass my details onto my local Carers Support Service

If you are aged 16 or over and caring for someone ages 18 or over, you have a right to a free statutory Carer's Assessment.
A Carer's Assessment is a chance to talk about your individual needs as a carer, and find out what help and support could be available to you from your Local Authority. It is usually carried out by Social Services, who can also look at the support needs of the person you care for an dhow they can help them.
You will be contacted directly for further details about your caring role and the person you care for.

Yes, please refer me for a statutory Carer's Assessment from the Local Authority

No, please do not refer me for a statutory Carer's Assessment from the Local Authority

Yes, you can contact me in the future for feedback on the support I received

Signature *

Date *

Tell us whether you accept cookies

Carer Identification and Referral Form

Section 1: Carer's Details

Section 2: Cared for person's details

Section 3: Reason for referral

Section 4: Consent

Hay Fever