Mind the Carer! Referral Form

Is this a self-referral or professional referral?

Self-referral
Professional referral.

Professional Referral Section

Referring professionals Name

First

Last

Referring professionals Organisation

Referring professionals Role

Referring professionals Language/s

Eligibility criteria (please tick all which apply)

Consent - Has the Carer consented to the referral?

Yes
No

Name of Surgery

Name of GP

GP Address

Address Line 1

Address Line 2

City

State

Zip Code

GP Phone

GP Email

Self-referral Section

To also be completed for Professional Referral

Carers Details

Date of Birth

Phone

Email

Address

Mental Health Conditions

Physical Health Conditions

Type of Carer

Individual
Multiple

Relationship to Cared For

Responsibilities outside of Carer duties: (job, other family etc.):

Type of Support needed

1:1 session
Weekly and monthly group sessions
Psychoeducation sessions

Are there any risks/safeguarding concerns we need to be aware of

Yes
No

If you selected yes please specify below

Please briefly summarise the state of the Carer's Mental Health at the time of referral and any risk factor/s that the team should be aware of

Have completed this referral on behalf of someone else

Yes
No

Gender

Sexuality

Ethnicity

Do you consider yourself to have any of the following

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Professional Referral Section

Self-referral Section

Carers Details