Referral Form for Universal Service

This form is for professionals to refer carers to the Universal Carers Service offered by Sheffield Carers Centre. After referral the carer will be sent a Carer Card and Welcome Pack with details of the support they can access, plus our monthly Enewsletter.

Before completing this form please make sure you:
1) read our referral criteria
2) have the carer’s consent to pass their information on to us
3) complete all the mandatory questions marked ’required’

We’ll record the personal data you supply on this form in accordance with our privacy notice. If you need any help with the form please email [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 number (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

Carer’s Date of Birth

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? (required)

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)

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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