Professionals Referral Form - Waltham Forest
Carers FIRST is an independent, charitable organisation supporting and helping people who look after a relative or friend Please complete this form if you would like to refer someone for support who lives in, or looks after someone who lives in Waltham Forest. Please provide us with as much information as possible and someone from our Carers Hub team will aim to contact them within 5 working days. If you require more urgent support please call us on 0300 303 1555. Thank you. Please ensure the person you are completing this form for is aware of the referral.
1 Referrer's full name
2 Organisation referrer works for:
3 Referrer's contact details:
please provide us with a telephone number & email address
4 Carer's Title, eg Mr, Mrs, Ms
5 Carer's full name:
6 Carer's date of birth:
7 Carer's contact telephone numbers
8 Carer's email address:
9 Carer's address, including postcode:
10 Are you aware if the carer has had a Carers Assessment?
11 If Yes, please tell us approximate month and year
12 What is the carer's first language:
13 In an interpreter required?
14 Does the carer have any medical conditions?
If yes, please give details
15 Name of the person being cared for:
16 Health condition
17 What is their relationship to the carer? e.g. mother, son, friend
18 What reason(s) are you referring the carer for?
please tick all that apply
Carer would like some information and advice on support available
Carer is struggling with their caring role and would like some help
Carer would like some practical support e.g. information about benefits
or help in the home
19 If you have ticked "other" please provide some details:
20 How did you hear about us?
21 Is there anything else you would like to tell us about the caring role?
22 Are there any known safeguarding issues or risks which Carers FIRST should be aware of?
If yes, please give brief details. If no, please type "none"
23 Privacy Notice. Please tick that you have read and understood.
Carers FIRST will collect and store in paper files and electronically, relevant information about you and your caring situation. We will collect, store and use the information you provide in a manner that is compatible with the General Data Protection Regulation (GDPR).  Please refer to our Privacy Notices for more details which are available on our website.
Yes I have read and understood