Website Self Referral Form
Carers FIRST is an independent, charitable organisation supporting and helping people who look after a relative or friend Please complete this form if you live in, or look after someone who lives in Medway, Lincolnshire, Waltham Forest, Haringey, Hackney, Newham or Essex. Please provide us with as much information as possible and someone from our Carers Hub team will contact you as soon as possible. If you require more urgent support please call us on 0300 303 1555.

If you are completing this on behalf of a relative or friend please ensure that they are fully aware that you are making the referral.  Thank you.
1 Title, eg Mr, Mrs, Ms
2 Full name:
3 Address:
4 Postcode:
5 Date of birth:
6 Home telephone:
7 Mobile telephone:
8 Email address:
9 What is your first language:
10 Do you require an interpreter?
11 Are you in receipt of any benefits?
If yes, please give any details you have
12 Approximately how many hours of care do you provide each week?
13 Do you have any medical conditions?
If yes, please give details
14 Name of person you are caring for:
15 Address (if different to your own)
16 Health condition
17 What is their relationship to you? e.g. mother, son, friend
18 What would you like support with?
tick all that apply
a) I would like information and advice on support available
b) I need some practical support, eg help in the home
c) I am struggling with my caring responsibilities and would like some help
d) Other
19 If you have ticked "other" please provide some details:
20 Is there anything else you would like to tell us about your caring role?
21 It would help us to ensure we are providing relevant services to all carers if you are able to answer the following questions. Please leave blank if you prefer not to say:
Religious beliefs
23 How did you hear about us?