Referral Form for Carer Assessment

This form is for professionals to refer an individual for a carers assessment. This also gives access to the Universal Carers Service, which meets many carers’ needs. Before you complete this form please be aware: 1) We operate waiting lists so please read our guidance on referral for assessment 2) You must have the carer’s consent to pass their information onto us 3) You will need to complete all the compulsory questions marked (required) We’ll process and record the personal data on this form in accordance with our privacy notice. If you need any help completing this form please contact [email protected] or call 0114 278 8942.

SECTION 1: These questions are about the carer you are referring to us and their caring role

Carer’s First Name(s) (required)

Carer’s Surname (required)

Carer’s Home Address (required)

Carer’s Postcode (required)

Carer’s Phone (landline and/or mobile) (required)

Carer’s Email Address. Please note if this is not provided we won’t be able to send our monthly Carers News! with updates about our services, activities and other carer related news. Carers can unsubscribe from the Enews at any time

Care’s Date of Birth (required)

Please outline any accessibility issues or other support the carer needs to access our services

How long as the carer been caring in their current role?

SECTION 2: These questions are about the person being cared-for.

Cared-for person’s First Name(s)

Cared-for person’s Surname

What is the cared-for person’s primary (main) condition or disability (required)

Cared-for person’s Date of Birth

What is the relationship of the carer to the cared-for person? The carer is the (required)

Does the person being cared-for have a case open with Adult Social Care?

If you are referring someone who cares for more than one person please provide details in the box below

Please tell us about the carer’s situation and what support needs you think they have (required)

Please do not ring us until after you have sent in the referral form as we cannot have a Triage conversation with you until we have received all the essential information?

Is this referral urgent? (required)

Please confirm the carer has consented to you passing on the information in this form (required)

SECTION 3: These questions are about you as the referring professional.

Your First Name(s) (required)

Your Surname (required)

Your Organisation and Team (required)

Your Job Title (required)

Your Phone (landline and/or mobile) (required)

Your Email Address (required)

The information you provide with this form will be collected and stored by Sheffield Carers Centre. We will always store your personal details securely and in line our Privacy Policy. Please tick the box below to confirm you understand. (required)

I understand

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