Make a referral

REFERRAL TO LEWISHAM CARERS INFORMATION ADVICE & SUPPORT SERVICE

Please complete the form below or Download AND print the document below

Where did you hear about Lewisham Carers (IAS) Service? *
Carer details
Name of carer *
Name of carer
Gender
Is there anyone else in your home who helps with caring?
Do you have mobility issues? *
Do you have physical health issues *
Are you currently employed?
Would you like support to find employment? *
Cared for details
Name of person to be cared for *
Name of person to be cared for
Date of birth *
Date of birth
Gender
Please tick any of the following that apply
Has a Care Needs Assessment been carried out by the local authority?
Reasons for referral
For third party referral
Name of referrer
Name of referrer
Has the carer consented this referral?
GDPR: GENERAL DATA PROTECTION REGULATION 2018
We will never share your personal data with any outside agency or company without your permission unless required to do so by law. You are entitled to view your record at any time by giving us 48 hours notice in writing.
Carer consent
I agree that YVHSC staff and volunteers can process my personal details to enable appropriate support to be identified for me and the person I care for. *
I give my permission for my personal details to be shared with other partners involved in the delivery of the service in accordance with the new General Data Protection Regulation (GDPR) *
I understand I can withdraw my consent at any time by contacting info@helpingcarersinlewisham.org.uk or 020 3886 0970 *
I confirm that I am happy to be contacted by
Cared for person consent
I agree that YVHSC staff and volunteers can process my personal details to enable appropriate support to be identified for me and my carer.
I give my permission for my personal details to be shared with other partners involved in the delivery of the service in accordance with the new General Data Protection Regulation (GDPR)
I understand I can withdraw my consent at any time by contacting info@helpingcarersinlewisham.org.uk or 020 3886 0970