gloucestershirecarershub.co.uk
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185.41.10.238
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URL:
https://gloucestershirecarershub.co.uk/refer-a-carer/
Submission: On May 16 via manual from GB — Scanned from GB
Submission: On May 16 via manual from GB — Scanned from GB
Form analysis 2 forms found in the DOM
GET https://gloucestershirecarershub.co.uk/
<form role="search" method="get" class="et_pb_searchform" action="https://gloucestershirecarershub.co.uk/">
<div>
<label class="screen-reader-text" for="s">Search for:</label>
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<input type="hidden" name="et_pb_include_pages" value="yes">
<input type="submit" value="Search" class="et_pb_searchsubmit" style="">
</div>
</form>POST /refer-a-carer/#wpcf7-f318-p1274-o1
<form action="/refer-a-carer/#wpcf7-f318-p1274-o1" method="post" class="wpcf7-form init" aria-label="Contact form" novalidate="novalidate" data-status="init">
<div style="display: none;">
<input type="hidden" name="_wpcf7" value="318">
<input type="hidden" name="_wpcf7_version" value="5.7.5.1">
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<input type="hidden" name="_wpcf7_recaptcha_response"
value="03AL8dmw_U-JbTwcmv-aAtlAFVKQeDFQfi45w8I0rKPDTRF76G3W7HP3Xg1GDeRWOgxf1kyGSC6SeKJJoDPC9gp4kuBI-3K0OGjEVFSFqBts4BGryf2twiw2nDY7ZM79zfHWgbXGqCfdxG2I5OiEKFLYPuKdBGd3WJ0w5oH9EP5J9vKKCsXNG5DHUVkynbHBnFjPNimFiYwl4dpo3oJNGieXn607tex4-1tChTslmJyP4sK7UUQqIlAD_69eCuYAmROSZe7wsAyfAiwOZyJ3QYh9b0GE5HMun8YfjH5X63uBgZrkTBb96qTCQt5vS9nE3CiaCVibcduGowdh9eno2gkQ0c6DVzw-ufothxj960UrYAP2_tszl1DldrmwLwGJdApxEhA_VwW2L_i_EQrkUCMZcmhD3P8ejU9dR5Mt5buYLZFR7fMElPZ0-ZK4k7PKD1yYc7sIVe5xZrvO9CqtMY_H8ywPPKfx5LlKTE5brIrG9ALQI2cRvGbb5QjAOp3mKPpsQL9VoGQLQ7s-Gu6V1iyrMiDK3CnPAbwnS8J9e-m8iqqQI71R-prhVSvDRhWvM9zWHH9wFhwA3p">
</div>
<style>
h3 {
font-size: 16pt
}
</style>
<h3>Carers Details:</h3>
<p><label>Title*</label><span class="wpcf7-form-control-wrap" data-name="title"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required"><span class="wpcf7-list-item first"><input type="checkbox" name="title[]" value="Mr"><span
class="wpcf7-list-item-label">Mr</span></span><span class="wpcf7-list-item"><input type="checkbox" name="title[]" value="Mrs"><span class="wpcf7-list-item-label">Mrs</span></span><span class="wpcf7-list-item"><input type="checkbox"
name="title[]" value="Miss"><span class="wpcf7-list-item-label">Miss</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="title[]" value="Other"><span class="wpcf7-list-item-label">Other</span></span></span></span>
</p>
<p><label>Full Name*</label><span class="wpcf7-form-control-wrap" data-name="full-name"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text"
name="full-name"></span></p>
<p><label>Known as</label><span class="wpcf7-form-control-wrap" data-name="known-as"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="known-as"></span></p>
<p><label>Home Address*</label><span class="wpcf7-form-control-wrap" data-name="home-address"><textarea cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required" aria-required="true" aria-invalid="false"
name="home-address"></textarea></span></p>
<p><label>Tel No.*</label><span class="wpcf7-form-control-wrap" data-name="tel-no"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text"
name="tel-no"></span></p>
<p><label>Mobile</label><span class="wpcf7-form-control-wrap" data-name="mobile"><input size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" value="" type="text" name="mobile"></span></p>
<p><label>Email (or n/a)</label><span class="wpcf7-form-control-wrap" data-name="email"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email" aria-invalid="false" value="" type="email" name="email"></span></p>
<p><label>DOB* (DD/MM/YYYY)</label><span class="wpcf7-form-control-wrap" data-name="dob"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text"
name="dob"></span></p>
<p><label>Age*</label><span class="wpcf7-form-control-wrap" data-name="age"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required"><span class="wpcf7-list-item first"><input type="checkbox" name="age[]" value="18-25"><span
class="wpcf7-list-item-label">18-25</span></span><span class="wpcf7-list-item"><input type="checkbox" name="age[]" value="26- 64"><span class="wpcf7-list-item-label">26- 64</span></span><span class="wpcf7-list-item"><input type="checkbox"
name="age[]" value="65-84"><span class="wpcf7-list-item-label">65-84</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="age[]" value="85+"><span class="wpcf7-list-item-label">85+</span></span></span></span></p>
<p><label>Gender*</label><span class="wpcf7-form-control-wrap" data-name="gender"><span class="wpcf7-form-control wpcf7-radio"><span class="wpcf7-list-item first"><input type="radio" name="gender" value="Male"><span
class="wpcf7-list-item-label">Male</span></span><span class="wpcf7-list-item"><input type="radio" name="gender" value="Female"><span class="wpcf7-list-item-label">Female</span></span><span class="wpcf7-list-item last"><input type="radio"
name="gender" value="Non Binary"><span class="wpcf7-list-item-label">Non Binary</span></span></span></span></p>
<p><label>Employment Status*</label><span class="wpcf7-form-control-wrap" data-name="employment"><span class="wpcf7-form-control wpcf7-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="employment[]" value="Unemployed"><span
class="wpcf7-list-item-label">Unemployed</span></span><span class="wpcf7-list-item"><input type="checkbox" name="employment[]" value="Full time employed"><span class="wpcf7-list-item-label">Full time employed</span></span><span
class="wpcf7-list-item"><input type="checkbox" name="employment[]" value="Part time employed"><span class="wpcf7-list-item-label">Part time employed</span></span><span class="wpcf7-list-item"><input type="checkbox" name="employment[]"
value="Retired"><span class="wpcf7-list-item-label">Retired</span></span><span class="wpcf7-list-item"><input type="checkbox" name="employment[]" value="Unable to work"><span class="wpcf7-list-item-label">Unable to work</span></span><span
class="wpcf7-list-item last"><input type="checkbox" name="employment[]" value="Prefer not to say"><span class="wpcf7-list-item-label">Prefer not to say</span></span></span></span></p>
<p><label>Is the Carer a Veteran*</label><span class="wpcf7-form-control-wrap" data-name="veteran"><span class="wpcf7-form-control wpcf7-checkbox"><span class="wpcf7-list-item first"><input type="checkbox" name="veteran[]" value="Yes"><span
class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="veteran[]" value="No"><span class="wpcf7-list-item-label">No</span></span></span></span></p>
<p><label>Ethnicity*</label><span class="wpcf7-form-control-wrap" data-name="ethnicity"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required"><span class="wpcf7-list-item first"><input type="checkbox" name="ethnicity[]"
value="Any other ethnic group"><span class="wpcf7-list-item-label">Any other ethnic group</span></span><span class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="Any other mixed background"><span
class="wpcf7-list-item-label">Any other mixed background</span></span><span class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="Asian/ Asian British- Bangladeshi"><span class="wpcf7-list-item-label">Asian/ Asian
British- Bangladeshi</span></span><span class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="Asian/ Asian British- Pakistani"><span class="wpcf7-list-item-label">Asian/ Asian British- Pakistani</span></span><span
class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="Asian/ Asian British-Indian"><span class="wpcf7-list-item-label">Asian/ Asian British-Indian</span></span><span class="wpcf7-list-item"><input type="checkbox"
name="ethnicity[]" value="Black - other background"><span class="wpcf7-list-item-label">Black - other background</span></span><span class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]"
value="Black/ Black British- African"><span class="wpcf7-list-item-label">Black/ Black British- African</span></span><span class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="Black/ Black British- Caribbean"><span
class="wpcf7-list-item-label">Black/ Black British- Caribbean</span></span><span class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="Chinese"><span class="wpcf7-list-item-label">Chinese</span></span><span
class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="Gypsy or Irish Traveller"><span class="wpcf7-list-item-label">Gypsy or Irish Traveller</span></span><span class="wpcf7-list-item"><input type="checkbox"
name="ethnicity[]" value="Mixed- White & Asian"><span class="wpcf7-list-item-label">Mixed- White & Asian</span></span><span class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]"
value="Mixed- White and Black Caribbean"><span class="wpcf7-list-item-label">Mixed- White and Black Caribbean</span></span><span class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="White and Asian"><span
class="wpcf7-list-item-label">White and Asian</span></span><span class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="Not obtained/ refused"><span class="wpcf7-list-item-label">Not obtained/ refused</span></span><span
class="wpcf7-list-item"><input type="checkbox" name="ethnicity[]" value="Other- White background"><span class="wpcf7-list-item-label">Other- White background</span></span><span class="wpcf7-list-item"><input type="checkbox"
name="ethnicity[]" value="White British"><span class="wpcf7-list-item-label">White British</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="ethnicity[]" value="White Eastern European"><span
class="wpcf7-list-item-label">White Eastern European</span></span></span></span></p>
<p><label>GP name, Tel no. and Practice address:</label><span class="wpcf7-form-control-wrap" data-name="practice-address"><textarea cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea" aria-invalid="false"
name="practice-address"></textarea></span></p>
<p><label>Does the carer have any communication needs?* (e.g. hearing impairment, visual impairment, translation services required.) Please note that translation services can be arranged for a carer, please note this if required on the
form.</label><span class="wpcf7-form-control-wrap" data-name="communication-needs"><textarea cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required" aria-required="true" aria-invalid="false"
name="communication-needs"></textarea></span></p>
<p><label>Will the carer experience substantial difficulty in understanding, retaining or using information given, or in communicating their views, wishes or feelings? If so, consider if advocate needed - please indicate this need
below</label><span class="wpcf7-form-control-wrap" data-name="substantial-difficulty"><textarea cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea" aria-invalid="false" name="substantial-difficulty"></textarea></span></p>
<div style="padding: 20px; margin:20px 0; background-color:#e5e5e5;">
<p>Information from Gloucestershire Carers Hub on your privacy</p>
<p>We collect and use your personal information to provide carer support services effectively and to meet our statutory duties under the Care Act 2014 and other relevant legislation. We will collect only the personal information we need to
perform our duties. We will collect your name and contact details as well as information relevant to your support needs. The Gloucestershire County Council and PeoplePlus Privacy Notice outlines the types of information we are required to
capture, the reasons for this, and our commitments to privacy regarding all information that we hold.</p>
<p>As a referrer you should provide a copy of our Privacy Notice, either electronically or in hard copy, to the carer.
<a href="/wp-content/uploads/2023/03/PP-078-Privacy-Notice-for-our-Customers-and-Learners-1-6-Jun-22-2.pdf" role="link">Our Privacy Notice can be found here</a>.</p>
<p><span class="wpcf7-form-control-wrap" data-name="agree"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox"><span class="wpcf7-list-item first last"><input type="checkbox" name="agree"
value="Please tick to confirm that you have provided the carer with details of our Privacy Notice."><span class="wpcf7-list-item-label">Please tick to confirm that you have provided the carer with details of our Privacy
Notice.</span></span></span></span></p>
</div>
<h3>Carers Caring Details:</h3>
<p><label>Condition(s) of cared for?*</label><span class="wpcf7-form-control-wrap" data-name="condition-care-for"><textarea cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required" aria-required="true"
aria-invalid="false" name="condition-care-for"></textarea></span></p>
<p><label>Who are they providing care for?*</label><span class="wpcf7-form-control-wrap" data-name="providing-care-for"><textarea cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required" aria-required="true"
aria-invalid="false" name="providing-care-for"></textarea></span></p>
<p><label>How long has the Carer provided this caring role?*</label><span class="wpcf7-form-control-wrap" data-name="caring-rol"><textarea cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required"
aria-required="true" aria-invalid="false" name="caring-rol"></textarea></span></p>
<p><label>Estimated total hours of caring each week*</label><span class="wpcf7-form-control-wrap" data-name="hours"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required"><span class="wpcf7-list-item first"><input
type="checkbox" name="hours[]" value="Under 10 hours per week"><span class="wpcf7-list-item-label">Under 10 hours per week</span></span><span class="wpcf7-list-item"><input type="checkbox" name="hours[]"
value="10 - 20 hours per week"><span class="wpcf7-list-item-label">10 - 20 hours per week</span></span><span class="wpcf7-list-item"><input type="checkbox" name="hours[]" value="21 - 35 hours per week"><span
class="wpcf7-list-item-label">21 - 35 hours per week</span></span><span class="wpcf7-list-item"><input type="checkbox" name="hours[]" value="36 - 50 hours per week"><span class="wpcf7-list-item-label">36 - 50 hours per
week</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="hours[]" value="51+ hours per week"><span class="wpcf7-list-item-label">51+ hours per week</span></span></span></span></p>
<p><label>What type of support does the Carer provide?*</label><span class="wpcf7-form-control-wrap" data-name="carer-provide"><textarea cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required" aria-required="true"
aria-invalid="false" name="carer-provide"></textarea></span></p>
<p><label>Initial concerns and the reason for the referral?*:</label><span class="wpcf7-form-control-wrap" data-name="concerns"><span class="wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required"><span class="wpcf7-list-item first"><input
type="checkbox" name="concerns[]" value="Prevent carer breakdown"><span class="wpcf7-list-item-label">Prevent carer breakdown</span></span><span class="wpcf7-list-item"><input type="checkbox" name="concerns[]"
value="Managing physical / mental health"><span class="wpcf7-list-item-label">Managing physical / mental health</span></span><span class="wpcf7-list-item"><input type="checkbox" name="concerns[]"
value="Skills and understanding of caring role"><span class="wpcf7-list-item-label">Skills and understanding of caring role</span></span><span class="wpcf7-list-item"><input type="checkbox" name="concerns[]"
value="Emotional Support"><span class="wpcf7-list-item-label">Emotional Support</span></span><span class="wpcf7-list-item"><input type="checkbox" name="concerns[]" value="Social activities / Time for self"><span
class="wpcf7-list-item-label">Social activities / Time for self</span></span><span class="wpcf7-list-item"><input type="checkbox" name="concerns[]" value="Managing finances"><span class="wpcf7-list-item-label">Managing
finances</span></span><span class="wpcf7-list-item"><input type="checkbox" name="concerns[]" value="Support to remain in employment"><span class="wpcf7-list-item-label">Support to remain in employment</span></span><span
class="wpcf7-list-item"><input type="checkbox" name="concerns[]" value="Contingency planning"><span class="wpcf7-list-item-label">Contingency planning</span></span><span class="wpcf7-list-item"><input type="checkbox" name="concerns[]"
value="Bereavement Support"><span class="wpcf7-list-item-label">Bereavement Support</span></span><span class="wpcf7-list-item last"><input type="checkbox" name="concerns[]" value="Other"><span
class="wpcf7-list-item-label">Other</span></span></span></span></p>
<p><label>Please provide any further information*</label><span class="wpcf7-form-control-wrap" data-name="further-information"><textarea cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required" aria-required="true"
aria-invalid="false" name="further-information"></textarea></span></p>
<h3>Referrer Details</h3>
<p><label>Name of referrer*</label><span class="wpcf7-form-control-wrap" data-name="referred-by"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text"
name="referred-by"></span></p>
<p><label>Job title*</label><span class="wpcf7-form-control-wrap" data-name="job"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="job"></span>
</p>
<p><label>Name of GP surgery/ Organisation/ Agency (If statutory service please specify team and location)*</label><span class="wpcf7-form-control-wrap" data-name="referred-organisation"><input size="40"
class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="referred-organisation"></span></p>
<p><label>Email*</label><span class="wpcf7-form-control-wrap" data-name="referred-email"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text"
name="referred-email"></span></p>
<p><label>Tel No*</label><span class="wpcf7-form-control-wrap" data-name="referred-tel"><input size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text"
name="referred-tel"></span></p>
<div class="submit">
<p><input class="wpcf7-form-control has-spinner wpcf7-submit" type="submit" value="Send"><span class="wpcf7-spinner"></span></p>
</div>
<div class="wpcf7-response-output" aria-hidden="true"></div>
</form>Text Content
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* What type of Carer are you? * I need a break * I need some emotional support * What is the Carers Emergency Scheme (CES)? * Peer Support – Buddy Up scheme * Life after Caring * Resources * What do you offer? * Printable Marketing * How do I refer? * Information and Training Sessions * Monthly Events * Be Empowered * Training * Carer Aware * What is Carer Aware? * Carer Aware Discount Card * Businesses offering a discount * Free champion Carer Aware training * Employer Toolkit * Our Partners * Our Short Break Providers * Our Carers Emergency Scheme Providers (partners) * Our Counselling Partners * Contact Us * Contact Us * Support Organisations * Home * About Us * What we do * Meet the Team * Assessment Process * Health Liaison * Hub News * Volunteer with Us * For Carers * Am I a Carer? * What type of Carer are you? * I need a break * I need some emotional support * What is the Carers Emergency Scheme (CES)? * Peer Support – Buddy Up scheme * Life after Caring * Resources * What do you offer? * Printable Marketing * How do I refer? * Information and Training Sessions * Monthly Events * Be Empowered * Training * Carer Aware * What is Carer Aware? * Carer Aware Discount Card * Businesses offering a discount * Free champion Carer Aware training * Employer Toolkit * Our Partners * Our Short Break Providers * Our Carers Emergency Scheme Providers (partners) * Our Counselling Partners * Contact Us * Contact Us * Support Organisations * Home * About Us * What we do * Meet the Team * Assessment Process * Health Liaison * Hub News * Volunteer with Us * For Carers * Am I a Carer? * What type of Carer are you? * I need a break * I need some emotional support * What is the Carers Emergency Scheme (CES)? * Peer Support – Buddy Up scheme * Life after Caring * Resources * What do you offer? * Printable Marketing * How do I refer? * Information and Training Sessions * Monthly Events * Be Empowered * Training * Carer Aware * What is Carer Aware? * Carer Aware Discount Card * Businesses offering a discount * Free champion Carer Aware training * Employer Toolkit * Our Partners * Our Short Break Providers * Our Carers Emergency Scheme Providers (partners) * Our Counselling Partners * Contact Us * Contact Us * Support Organisations * Home * About Us * What we do * Meet the Team * Assessment Process * Health Liaison * Hub News * Volunteer with Us * For Carers * Am I a Carer? * What type of Carer are you? * I need a break * I need some emotional support * What is the Carers Emergency Scheme (CES)? * Peer Support – Buddy Up scheme * Life after Caring * Resources * What do you offer? * Printable Marketing * How do I refer? * Information and Training Sessions * Monthly Events * Be Empowered * Training * Carer Aware * What is Carer Aware? * Carer Aware Discount Card * Businesses offering a discount * Free champion Carer Aware training * Employer Toolkit * Our Partners * Our Short Break Providers * Our Carers Emergency Scheme Providers (partners) * Our Counselling Partners * Contact Us * Contact Us * Support Organisations Carer Self-Referral and Family Referral Form Professional Referral Form Carer Self-Referral and Family Referral Form Professional Referral Form 0300 111 9000 Mon, Wed & Fri 9am-5pm, Tues & Thurs 8am-8pm REFER A CARER All questions marked with an asterisk-*- are required CARERS DETAILS: Title*MrMrsMissOther Full Name* Known as Home Address* Tel No.* Mobile Email (or n/a) DOB* (DD/MM/YYYY) Age*18-2526- 6465-8485+ Gender*MaleFemaleNon Binary Employment Status*UnemployedFull time employedPart time employedRetiredUnable to workPrefer not to say Is the Carer a Veteran*YesNo Ethnicity*Any other ethnic groupAny other mixed backgroundAsian/ Asian British- BangladeshiAsian/ Asian British- PakistaniAsian/ Asian British-IndianBlack - other backgroundBlack/ Black British- AfricanBlack/ Black British- CaribbeanChineseGypsy or Irish TravellerMixed- White & AsianMixed- White and Black CaribbeanWhite and AsianNot obtained/ refusedOther- White backgroundWhite BritishWhite Eastern European GP name, Tel no. and Practice address: Does the carer have any communication needs?* (e.g. hearing impairment, visual impairment, translation services required.) Please note that translation services can be arranged for a carer, please note this if required on the form. Will the carer experience substantial difficulty in understanding, retaining or using information given, or in communicating their views, wishes or feelings? If so, consider if advocate needed - please indicate this need below Information from Gloucestershire Carers Hub on your privacy We collect and use your personal information to provide carer support services effectively and to meet our statutory duties under the Care Act 2014 and other relevant legislation. We will collect only the personal information we need to perform our duties. We will collect your name and contact details as well as information relevant to your support needs. The Gloucestershire County Council and PeoplePlus Privacy Notice outlines the types of information we are required to capture, the reasons for this, and our commitments to privacy regarding all information that we hold. As a referrer you should provide a copy of our Privacy Notice, either electronically or in hard copy, to the carer. Our Privacy Notice can be found here. Please tick to confirm that you have provided the carer with details of our Privacy Notice. CARERS CARING DETAILS: Condition(s) of cared for?* Who are they providing care for?* How long has the Carer provided this caring role?* Estimated total hours of caring each week*Under 10 hours per week10 - 20 hours per week21 - 35 hours per week36 - 50 hours per week51+ hours per week What type of support does the Carer provide?* Initial concerns and the reason for the referral?*:Prevent carer breakdownManaging physical / mental healthSkills and understanding of caring roleEmotional SupportSocial activities / Time for selfManaging financesSupport to remain in employmentContingency planningBereavement SupportOther Please provide any further information* REFERRER DETAILS Name of referrer* Job title* Name of GP surgery/ Organisation/ Agency (If statutory service please specify team and location)* Email* Tel No* Contact Details: Gloucestershire Carers Hub, c/o Omega Resource Group| Head Office|Omega House| Bond’s Mill| Stonehouse| Gloucestershire| GL10 3RF 0300 111 9000 carers@peopleplus.co.uk – Facebook – Twitter – Instagram PeoplePlus Group Ltd part of Staffline Group plc. 19-20 The Triangle, NG2 Business Park, Nottingham, NG2 1AE. 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