To refer an adult carer to Action for Carers Surrey | Action for Carers
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Refer an adult carer to Action for Carers Surrey

About this form

If you are a professional (such as an occupational therapist, social worker etc*) looking to refer an adult carer to our services, please complete the form below. NB This referral means a carer can access ALL our support for adults, including our Moving & Handling service, Young Adult Carer service (18-24) and Armed Services support.

If you’re looking to register yourself please visit this page.

To refer a young carer to our services, please visit this page.

*Please note that GPs should use the Carer’s Prescription here.

Professional referral form

  • Privacy Statement:

    Information will be processed securely and in line with current data protection legislation. Any personal or sensitive information, such as health and ethnicity, that is provided to Action for Carers Surrey (ACS) or shared with them by the carer may be recorded and is used for the purposes of providing advice, information and support to them in their caring role. Our Privacy Policy provides full details explaining why ACS collect their information, how we use it, who we may share it with and sets out their rights in relation to their data. You can find our privacy policy at www.actionforcarers.org.uk and it is recommended that the carer read this information. If the carer has any questions about how we use their data they may contact ACS on 01483 302748 or email dpo@actionforcarers.org.uk or write to Freepost Action for Carers Surrey.
  • I confirm that I have explained the privacy statement at the top of this form to the carer and how we use their data and where they can find out more about their rights in relation to their data.
  • I confirm consent has been gained from the carer (either verbally, by email or in writing) for Action for Carers Surrey to process the information contained on this form.

  • Carer details

  • This is optional but allows us to provide statistical data.
  • Date Format: DD slash MM slash YYYY
  • Please confirm if the carer has consented to be contacted by the following methods (we will need at least one). Please tick all that apply
  • If consent has been given, please enter the carer's email address.
  • If consent has been given, please enter the carer's landline number.
  • If consent has been given, please enter the carer's mobile phone number.
  • eg: Do not call before 10am, this is her daughter's phone number etc.
    0 of 100 max characters
  • 0 of 1000 max characters
  • 0 of 1000 max characters
  • 0 of 1000 max characters

  • Cared For(s)

  • 0 of 1000 max characters
  • 0 of 1500 max characters
  • 0 of 1500 max characters

  • Referrer details

  • Date Format: DD slash MM slash YYYY
  • I confirm I have gained the consents as indicated on this form and for Action for Carers Surrey to process and store the information contained on the form.
  • This field is for validation purposes and should be left unchanged.

 

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