Carers Emergency Response Service - Professional Referral Form

This form should only be used by health and social care professionals who are making a referral on behalf of someone else.

If you are a carer and would need to make a direct request for help, please use our Carers Emergency Response Service form.

Please complete each section of this form with as much detail as possible. This will help us process your referral faster.

A carer is defined as anyone, including children and adults who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support. The care they give is unpaid.
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Service user contact details (the person who requires care)
1. Title
2. Full name
3. House number / name and street
4. Town or city
5. Postcode
6. Phone number
7. Date of birth
9. What is the service user / client's ID number?
10. Does the service user have a Key Safe?
  
  Yes
  
  No
  
  Not sure
11. What are the access details for the Key Safe? For example, the combination lock code.
Referrer contact details
1. Please enter the contact details of the person making this referral.
2. Name of the person making this referral
3. Phone number
4. Employer name and job title
Please answer all questions honestly and include as much information as possible.