REFER YOURSELF

REFER YOURSELF
How did you hear about the Carers Hub?*
Other (tell us in the space below)
Title*
Name*

Your first nameYour surname
Address*

Street Address inluding flat and house number

Please include your local area

CityState / Province

Post code
Phone number 1 (mobile preferred)*
Phone number 2
Please add a landline if you have one
Email
Email address of carer.
Your date of birth*
dd/mm/yyyy
Your first language
Tell us your first language
Please note:

If you need an interpreter we cannot provide this service. We recommend you contact Glasgow North East Carers: www.gnecarerscentre.com

Equalities and Diversity Information

We ask these questions to help us ensure that we provide support to all carers, no matter what their identity or ethnicity. These questions are voluntary, but if you answer, this will help us give you the support that is most helpful for your individual needs.
Do you have a disability or long term health condition yourself? If so, please let us know what that is.
Employment Status
Religious Affiliation
Gender Identity - please describe how you identify.
Select the terms with which you most identify even if it is the same as above.
Pronouns - how would you like to be addressed?
How would you describe your sexual orientation?
Ethnicity
White (Includes any White background)
Asian or Asian British
Black, African, Black British or Caribbean
Mixed or multiple ethnic groups
Another ethnic group
CONSENT TO STORE & PROCESS DATA
Glasgow East End Community Carers will store and process this information, and any subsequent information you provide, in a secure and sensitive manner in line with General Data Protection Regulations (GDPR). This information may be used and shared anonymously with other partner organisations for reporting and monitoring purposes. GEECC will not disclose personal information to other organisations and/or individuals without explicit consent, unless an individual’s welfare is at risk.

Further details on how we use and protect your data can be found here.
Consent to store & process data*

I consent to Glasgow East End Community Carers storing and processing my personal information. By ticking this box you are giving written consent to the above conditions.
YOUR COMMUNICATION PREFERENCES
From a practical point of view, it is helpful to be able to contact you by text, phone, email and post. Sometimes a quick call is all that is required and at other times it may be more appropriate to share written information by email or post.
Permission to contact

I am happy for GEECC to use discretion to contact me using any of the details I have provided.
I am only happy to be contacted in the following ways:*

TextPhoneEmailLetter
Our office hours are usually 9am-5pm, Monday-Thursday, 9am-12pm Friday. Let us know the best time to contact you.
PERMISSION TO SHARE
This section will apply if we go on to provide support that may require us to contact other agencies on your behalf e.g. local council, health services, education or social work.
I agree to Glasgow East End Community Carers contacting other organisations on my behalf, where I have been consulted and have given my explicit consent at the time.*

YesNo
Should be Empty:

REFER YOURSELF

Please note:

ABOUT THE PERSON YOU CARE FOR - YOUR CARING ROLE

Equalities and Diversity Information

CONSENT TO STORE & PROCESS DATA

YOUR COMMUNICATION PREFERENCES

PERMISSION TO SHARE