Registration and referral

If you are a parent Carer (caring for someone under 18) please see our Parent Carer information page

Referrer details

Name of referrer (if applicable)

Telephone:

Email:

Organisation/Role:

Carer details

Name:

Date of referral:

Address

Postcode

Home Telephone

Mobile

Email Address

Date of Birth

Gender

Age

Ethnicity

Marital Status

Dependants

Language Spoken (state preferred language)

GP Surgery and Telephone number

Is the Carer already a member to DCA?

Length of time as a Carer?

Has the Carer ever had a Carers Assessment?

Details of the Cared For 1

Name

Diagnosis/health condition

Relationship to Carer

DOB & Age

Address

Details of the Cared For 2

Name

Diagnosis/health condition

Relationship to Carer

DOB & Age

Address

Other information

Are there any risks identified we should know? (ie animals in property, no lone workers, client hard of hearing, sensitivity towards cared for, etc)

On a scale of 1-5 how stressed or anxious are you/is the carer about the caring situation?

How is health impacted by caring?

Are social care, other agencies or wider family/friends supporting?

What support would improve the caring situation?

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