Self-referral form for adult carers

Notice

If you have any questions or would like to speak to an Adult Carers Support Worker before completing this form, please contact the team on 020 8867 2380 or email support@richmondcarers.org

GDPR Agreement *

I consent to having this website store my saved or submitted information so Richmond Carers Centre can respond to my enquiry. You can read Richmond Carers Centre's privacy policy here

Carer's details

Your Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Your Phone Number *

Your email *

What is the best way to make contact with you? *

Date of Birth *

Do you have a long term health condition or disability? *

Yes
No
Unsure

Gender *

Please describe your health condition or disability *

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About the person you care for

(person with the care need)

Name of the person you care for *

First

Last

NOTE: If you care for more than one person, you can add their details further down this form

Date of Birth *

Relationship to you *

Please describe your relationship *

What is the person you care for's condition/disability? *

Does the person you care for live with you? *

Please give the address or living arrangement *

Do you care for a second person?

Name of the second person you care for *

First

Last

Date of Birth *

Relationship to you *

Please describe your relationship *

What is the second person you care for's condition/disability? *

Does the second person you care for live with you? *

Please give the address or living arrangement *

Do you care for a third person?

Name of the third person you care for *

First

Last

Date of Birth *

Relationship to you *

Please describe your relationship *

What is the third person you care for's condition/disability? *

Does the third person you care for live with you? *

Please give the address or living arrangement *

Do you care additional people?

A support worker will contact you to take details of any additional people you care for.

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Put us in the picture

Brief description of your caring responsibilities *

Is there anybody under the age of 18 who lives with the cared for person or who provides additional care *

Is there anybody aged between 18-25 who lives with the cared for person or who provides additional care *

Please provide details of anybody under the age of 18 who lives with the cared for person or who provides additional care *

Please provide details of anybody aged between 18-25 who lives with the cared for person or who provides additional care *

Have you had a Carer's Assessment? *

Yes
No
Unsure

If you are a Richmond resident, you are entitled to a Carer's Assessment by Richmond Council’s Adult Social Care team. It is simply a conversation with you that helps the Local Authority understand the impact that your caring role may have on you and how they can support you.

Is there a specific issue that Richmond Carers Centre can help you with? *

Are you in touch with other organisations to support you in your caring role? *

Please list the other organisations *

What support would you like from Richmond Carers Centre? *

Information and advice
Contact with other carers
Activities and breaks
Newsletter and information
Emotional support
Counselling service
Information and training workshops
Benefits and financial advice

(tick all applicable)

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