Carer Referral Form

Carer Details
Name*

First NameLast Name
Heading
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

DayMonthYear
Date
Email
example@example.com
Would you like to subscribe to our free mailing list?

YesNo
Gender*

MaleFemaleNon-BinaryPrefer not to say
Ethnicity*

Are you submitting this referral on behalf of someone else?*

YesNo
Name*

First NameLast Name
If you are submitting this on behalf of an organisation, please provide your job title.
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Cared For Details
How many people do you care for?*

12 or more
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Does the cared for person(s) live with you?*

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cared for(s) condition*

General Details
How long have you been in your caring role?*
How many hours are spent caring each week?*
Are you willing to provide care?

YesNo
Do you provide help with?*

MedicationPersonal CareDomestic TasksTransportEmotional SupportFinancesOther
If you said 'Other' please provide us with a brief description of the support you provide
Is there something specific that you would like to talk to us about?

How would you like to be contacted (tick all that apply)

TelephoneEmailMeet with us in personVia postVideo call (where applicable)

Data Protection and your privacy
To provide you with the most appropriate information and advice, we may ask you for details of your caring role and the person(s) you care for.

Any information you provide will be processed in line with all relevant data protection legislation and laws.

If you consent to us processing and storing your personal details, we will never share them with third parties unless you give express permission for us to do so.

You can withdraw this permission at any time.

If you are making this referral on behalf of another person, please ensure that you have sought their consent to contact us and confirmed that you have explained how North Lanarkshire Carers Together will store and use this information.

Our usual communication methods with you are via email, phone calls and by post if necessary.

Do you consent to North Lanarkshire Carers Together using these methods to contact you?

Our full data protection and privacy policy is available at www.carerstogether.org
Do you consent to North Lanarkshire Carers Together storing and processing your personal information?*

YesNo
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