Anticipatory Care Plan Referral Form

Lanarkshire Carers Referral Form
Please note, not all sections of this form need to be completed to make a referral but any additional information you provide at this stage will be helpful. Certain information must be provided in order for us to deal with your request (*denotes manadatory information).

You can also make a referral by telephone. Please call us on 01698 428090, ensuring you have all of the relevant information.
Referral Details

Please tell us a bit about the person whom you are referring. The information you provide will allow us to support them effectively.
First Name:*
Surname:*
Address:*
Town/City:*
District*
Postcode:*
Email address:
Telephone number:*
CHI Number:*
Gender:*

MaleFemaleTransgenderPrefer not to say
Ethnicity:
Is interpretation required?

YesNo
Is this person in a caring role? (Looking after a family member, friend or neighbour with a physical or mental illness, a disability, frailty or addiction issue).

YesNoUnknown/prefer not to say
Do you know if the individual is in contact with other agencies or third sector organisations?
Please detail

Referrer Details

Please tell us a bit more about your referral and how we may support you.
Name of person making referral:*
GP Practice:*
Telephone number:*
Email address:*
Please use this space to provide any additional information (Optional):
Is this a priority referral?*

YesNo
If yes, please state why:

Your Privacy

Please read this statement carefully and let us know if you are happy for us to store and process your personal information.
Lanarkshire Carers will store and process the information provided on this referral form, or any subsequent information provided, in a secure and sensitive manner in line with relevant data protection laws. This information may be used and shared anonymously with other partner organisations for reporting and monitoring purposes. Lanarkshire Carers will not disclose any personal information provided with other organisations or individuals without explicit consent, unless a person’s safety and well-being is at risk.

Further details on how Lanarkshire Carers uses personal information can be found on our website: www.lanarkshirecarers.org.uk/privacy

A printed version of this policy can also be provided on request.

I, (the person making the referral) have explained to the individual how their personal information will be used and obtained their permission to share this information with Lanarkshire Carers.
Consent to store and process personal information:*

YesNo
Please enter the message as it's shown:*
Should be Empty: