Referral Details Part 1
CARER DETAILS Sections below to be completed by the Referrer.
Name in full
Date of birth
Address with postcode
Landline phone number
Work phone number
Mobile phone number
Email address
Reason for referral?
Gender	☐	Male	☐	Female	☐	Not known
Ethnic Group	☐	White	☐	Mixed/multiple ethnic	☐	Asian, Asian Scottish, Asian British
☐	African, Caribbean, Black	☐	Other ethnic background	☐	Ethnicity not known
☐	Carer does not want ethnicity recorded
GP and Surgery
Does carer have any communication needs Communication support needed	☐	No	☐	Yes (Record support needed below)
Has carer given their consent for referral?	Yes:	No:
Under data protection regulations, we cannot accept a referral without carer consent.

CARED FOR DETAILS Sections below to be completed by the Referrer.
Name in full
Date of birth
Address with postcode (if different from carer)
Gender	☐	Male	☐	Female	☐	Not known
Ethnic Group	☐	White	☐	Mixed/multiple ethnic	☐	Asian, Asian Scottish, Asian British
☐	African, Caribbean, Black	☐	Other ethnic background	☐	Ethnicity not known
☐	Cared for does not want ethnicity recorded
GP and Surgery
Relationship to the Carer
Is cared for in Hospital?	NO	YES	Don’t know	Which hospital & ward?
Tick appropriate box
Is cared for Palliative?	NO	YES	Don’t know
Tick appropriate box
Any Risks we should be aware of, should a Face to Face visit be required

Client group (tick at least one group but more where appropriate) Cared for - Illnesses and/or diagnosis	☐	Dementia	☐	Mental Health	☐	Learning Disability
☐	Autistic Spectrum Disorder	☐	Physical/sensory disability	☐	Neurological conditions (excluding dementia)
☐	Drug problem	☐	Alcohol problem	☐	Elderly frail
☐	Cancer	☐	Palliative Care	☐	Not known
☐	Other condition(s) (complete box below)

First Contact Details Part 2 Sections below can be completed by the Referrer, should they have any of this information. BCC will contact Carer to identify any missing information.
THE CARING ROLE
How long has the carer provided care	☐	Less than 1 year	☐	1 year but less than 5 years	☐	5 years but less than 10 years
☐	10 years but less than 20 years	☐	20+ years	☐	Not known
Average number of hours care provided a week	☐	Up to 4 hours	☐	5-19 hours	☐	20-34 hours
☐	35-49 hours	☐	50+ hours	☐	Not known
Type of care given by carer (all that apply) Details
Financial Support	☐
Help with medication	☐
Help with personal care	☐
Help with shopping, cleaning, domestic tasks	☐
Help with transport	☐
Supervision/emotional support	☐
Other (provide details)	☐
Not known	☐
Areas of carer’s life affected by caring (all that apply)	☐	Emotional well-being	☐	Employment	☐	(Not) Feeling valued	☐	Finance
☐	Future plans	☐	Health	☐	Life Balance	☐	Living environment
☐	Other/Not known
Is carer ABLE to provide care	☐	Yes	☐	No	☐	Not known
Is carer WILLING to provide care	☐	Yes	☐	No	☐	Not known

Is there a Power of Attorney in place	Yes	No	Not known
Does cared for have capacity Yes/No	Yes	No

Referrer Details Sections below to be completed by the Referrer.
Name
Job title
Organisation
Address
Telephone
Email
Date of submission

Please return your referral by email or post using the contact details below.

Other information discussed with Carer Sections below to be completed by BCC.
Carers Occupation/s	☐	Military service
Carers Health conditions
Carers Support Plan offer
☐	CSP agreed by carer	☐	CSP to discuss with CLW at next call	☐	CSP not appropriate	☐	CSP declined by carer	☐	Not known
Date completed	CLW Name