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Refer a Carer
Referrer Details
If you have any queries before completing this form, please contact the Carers Support Service on on 01202 128787. This form should not be completed by workers in Adult Social Care. Please note, this form should be used for carers supporting someone in Bournemouth, Christchurch or Poole only. If you wish make a referral for someone who cared for someone in Dorset, please contact Carer Support Dorset on 0800 368 8349 or visit their website www.carersupportdorset.co.uk
Name of Referrer
Organisation
Address
Telephone Number
Email
Has the carer consented to this referral?
Yes
No
Please note if the carer has not consented, we cannot accept the referral
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Carer Details
Please provide details of the carer below
Name of Carer
Address
Phone
Is it okay to leave a message if they do not answer?
Yes
No
Email
Carer preferred method of communication
Phone
Email
Post
Who do they care for?
Condition/diagnosis of the person they care for: e.g. dementia, mental health etc
Please tell us any other information that might help us better support the carer.
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