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Self Referral form

​To access our support, training, and events, please complete the self-referral form. It only takes a few minutes and helps us understand your needs so we can offer the most relevant support and opportunities.

 
Are you under 18?

If you are under 18 and caring for someone please contact YSS. You can find more information on their website or ask an adult to help you. Home | YSS

 

Social Prescribing and WorkWell (Work & Health Coaches)

If you would like to talk to a Social Prescriber or a Work & Health Coach – please contact your GP Practice and they will be able to put you in touch with your local Social Prescriber or Work & Health Coach.

 

We are currently receiving lots of calls for support. We apologise that it may take us a little longer than we would like to get back to you. In the meantime, you will receive a welcome pack and there is lots of information on the website to support you in your caring role.

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Please do get in touch with us if you need to talk to us – we’re here to help.

Self Referral Form

Please fill out the following form.

Do any of the following apply to your caring role? (please tick all that apply).
Parent Carer (cared for under 18)
Caring for someone who is elderly
Mental health conditions for the carer
Working Carer
The person being cared for is being discharged from hospital
The person you care for has been diagnosed as End of Life
Ethnicity
Asian African
Asian Bangladeshi
Asian British
Asian Chinese
Asian Indian
Asian Pakistani
Asian Punjabi
Asian Japanese
Asian Other
Black Other
Chinese British
White British
Mixed White
Mixed White and Asian
Mixed White and Black
Mixed White and Black African
Mixed White & Black Caribbean
Mixed Any Other Mixed Background
White European
White Irish
White Other
Mixed Asian
Mixed Black
Traveller/ Gypsy
Other Ethnic Group
Do not wish to disclose
Not Stated
Do you require an interpreter or any reasonable adjustments?
What is the best time for us to contact the Carer?
9am - 1pm
1pm - 5pm
5pm - 7pm
What kind of Information and Support are you looking for?

Consent

By completing this form I agree that Worcestershire Association of  Carers may hold confidential information about me and can share this on a need to know basis with other agencies that might assist me, including but not limited to other Voluntary Organisations and Health & Social Care Professionals.

 

I agree that Worcestershire Association of Carers can collect and process my personal information in line with UK GPDR.

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

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