For office use Key worker: ID No:
CARER Contact Details
Name in full	Date of Birth
Address with postcode
Telephone contact	Mobile No
Email address
GP and Surgery (if known)
CARER Consent	YES✔	NO✗	Don’t know
Has the CARER consented to contact from us?
Reason for referral Any specific issues
CARED FOR Details
Name in full	Date of Birth
Address with postcode (if different from above)
CARING Situation
Relationship to CARER
Illness or diagnosis of CARED FOR
Any risk factors we should be aware of
YES✔	Hospital/Ward
Currently in hospital?
Referred by
Name
Designation
Organisation
Address
Telephone
Email	Date of submission
Please return this referral to	Email to: admin@borderscarers.co.uk Post to: Borders Carers Centre, Brewerybrig, Low Buckholmside, Galashiels TD1 1RT