Professional Referrals

Welcome to the Carer Support West Sussex online referral form.

With this route, there are two crucial steps needed before you start the quick process
1. Express carer consent for Carers Support West Sussex to contact the carer. Without consent, the referral can go no further.
2. Carer personal details, such as name and caring role.

Once you have those details covered, please complete the referral form, which will securely transfer your referral to Carers Support. Once the referral is received, a wellbeing worker will make direct contact with the carer to discuss their caring role and how we can support them going forward. Referrals from professionals will be responded to within 10 working days. You will receive confirmation once we have made contact. Please do not chase your referral before 10 working days.

Referral Type *:

Name *:

Telephone Number:

Email Address *:

Organisation *:

What sector do you work in? *:

How did you hear about us?:

Position Held:

Would you like to receive our professional’s newsletter via email?:

Yes No

Title:

First Name *:

Last Name *:

Email Address:

Carers Contact Telephone Number:

Address Line 1:

Address Line 2:

Town:

County:

Postcode:

NHS Number (if known):

Date of Birth (if known):

GP Surgery (if known):

Please select Carer Health Issue if any:

Any Further Details on Carers Health:

Does this carer require any communication support? *:

Yes No

If Yes, please give details and inform if a translator is required:

Are you aware if this carer is already registered with Carers Support West Sussex? *:

Yes No

Please provide a brief synopsis of the caring situation and the reason for your referral *:

Carer Gender *:

Carer Sexual Orientation *:

Carer Ethnic Origin *:

Carer Religion or Belief? *:

Does the carer consider themselves to be disabled? *:

Yes No

Please enter the details of the person who is being cared for

Relationship To Carer *:

First Name *:

Last Name *:

Address (if different):

Postcode (if different):

Date of Birth:

Please select the main health issue of the Cared For:

Diagnosis of the person being cared for (if known):

Name of GP surgery (if known):

Please select the Carer category you feel best describes the caring situation (if known) *:

Please confirm the carer has given consent for you to refer them to Carers Support West Sussex and also for Carers Support West Sussex to contact them *:

Yes No

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Professional: Refer A Carer

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