Professional Referral

Professional Referral Form

Please note: Once you have completed and submitted this form, the information will

clear from the form for GDPR purposes. You will be able to see that the form has been safely and securely sent to us, as you will be notified at the bottom of the form on the screen. Thank you.

Any questions, do get in touch.

Worcestershire Adult Social Care

If you are making a referral from Worcestershire Adult Social Care, please use Liquidlogic Adults System (LAS) where we will then be able to process the referral.

Young Carers

If you are making a referral on behalf of a young carer (under the age of 18) please contact YSS - Refer | YSS

Community Mental Health Link Workers (CMHLW)

If you are making a referral for a Carer of someone who is being supported by the Community Mental Health Teams, please make the referral through your local Mental Health MDT meetings.

NHS Professionals

If you are an NHS professional, outside of the Mental Health services, please use this email to make a referral – WHCNHS.Carersworcs@nhs.net

Social Prescribing and WorkWell (Work & Health Coaches)

For all Social Prescribing and WorkWell referrals, if you are not a professional working for a GP Practice, please use this email address: hwicb.rbsocial@nhs.net.

All Other Professionals – please complete the form below.

We are currently receiving high demand for our services. We will be in touch as soon as possible. In the meantime, the carer will receive a welcome pack and there is lots of information on the website to support them in their caring role.

Please do let the carer know they can get in touch with us via the carer helpline or the webchat if they need to talk to us – we’re here to help.

Reason for Referral?

First name

Last name

Title

Address

Post Code

Phone number

Carer Email

Date of Birth

Carers GP Surgery:

Relationship to Cared For e.g. husband, sister, son

Do any of the following apply to your caring role? (please tick all that apply).

Parent Carer

Older Carer

Caring for someone who is elderly

Mental health problems for the carer

Mental health problems for the cared for

Working Carer

The person being cared for is being discharged from hospital

The person you care for has been diagnosed as End of Life

What is the best time for us to contact the Carer?

9am - 1pm

1pm - 5pm

5pm - 7pm

Does the carer require an interpreter or any reasonable adjustments?

Yes

Please provide details of any reasonable adjustments, or interpreter details, and the support that might be needed.

Cared For Information

Gender

Male

Female

Prefer not to say

Date of Birth

Main Illness or Disability

Other Illness or Disability

Has the person being cared for been diagnosed as End of Life?

Yes

Unsure

Referrer Details

Name:

Job Title:

Department/Team:

Organisation:

Contact Number

Email Address:

Consent

I confirm that the Carer has consented for their details to be shared with Worcestershire Association of Carers.

I Agree

By completing this form, I agree that Worcestershire Association of Carers may hold confidential information about me and/or the person I am referring and can exchange this on a need-to-know basis with other agencies who may assist me, including, but not limited to: Voluntary Organisations, Health & Social Care Professionals.

Worcestershire Association of Carers adheres to the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018, which govern how personal data is used by organisations in the UK.

Worcestershire Association of Carers will only collect personal information about you which is essential to enable us to support you. We will keep your personal information private and secure. We will not share your personal information with anyone else without your agreement, unless we are legally required to.

You have the right to ask that your personal information be kept up to date, the right to access your personal information and the right to ask to be forgotten on our records.

The ICO provides more about your rights and data protection - For the public | ICO