Online referral form version 2 - Carers of East Lothian

Carers of East Lothian is an independent charity delivering a wide range of support services to meet the needs of unpaid adult carers across the county.

Carers can ask for our support directly by a self-referral; or a professional working with the carer can refer someone to us.

If you are an unpaid carer and would like support, please tick Self-Referral below and complete the form with as much information as you can.

If you are a professional supporting an unpaid carer, please tick Professional Referral below and complete the form with as much information as possible.

We make every effort to protect your privacy and treat your personal information confidentially. If you would like to see our privacy notice please click here: https://www.coel.org.uk/privacy/

Comments
This field is for validation purposes and should be left unchanged.
Type of referral*
- Self referral
- Professional referral
Your Name (carer)*
Prefix First Last
Address*
Street Address Address Line 2 City/Town County Post Code Country
Preferred phone number*
Other phone number
Any other phone number you would like us to keep on record
Email Address*
Please enter in the box below or write ‘no email address’
Date Of Birth*
Gender*
Ethnic Group*
What year did you become a carer? (A rough estimate is fine)*
How did you hear about us?
Do you have any health conditions that impact on your caring role?
What health condition(s) does the person(s) you care for have?*
- Autistic Spectrum Disorder
- Dementia or Alzheimer’s
- Drug Addiction
- Alcohol Addiction
- Frail or Elderly
- Learning Disabilities
- Mental Health
- Neurological Condition
- Palliative
- Physical Disabilities
- Sensory Impairment
- Other – please enter in box below
Other
Is cared for person 16years old or younger?*
- Yes
- No
Brief description of caring situation and how it affects your life e.g. your health & wellbeing, employment, social life, relationships or anything else.*
Why are you contacting us today?*
To help us provide the support you need, please tick one or more from the following list. For more information about our services please go to: https://www.coel.org.uk/for-carers/our-services/
- Adult Carer Support Plan
- Breaks from Caring Grants (including Time for Me Fund)
- Crisis Grant (including Financial Insecurity Fund) for food, electricity/gas or transport
- Other Grant Funding (including Carers Trust Fund) e.g. for essential equipment or appliances
- Health and Wellbeing support
- Counselling Service
- Social Support e.g. support groups, events, workshops
- Benefit Check and / or help to apply for benefits
- Telephone Befriending
- Hospital Link Carer Support
- Mental Health Carer Support
- Parent Carer Support
- Legal Advice Clinic (info on guardianship, wills, power of attorney)
- Life after Caring (including bereavement support)
- Other -please enter in box below
Other
Is there anything else you want to tell us about your caring role or the support you need?
Please note – by completing this form you are consenting to Carers of East Lothian holding your contact information. We hold this so we can contact you by the methods you choose below to:
- provide carer support and information which may be helpful to you in your caring role and
- to let you know about events and opportunities relevant to your caring situation, including our newsletter (which we will refer to as generic info in the options below)
Please tell us how you would like us to contact you:*
- Yes to ALL types of contact and ALL types of info
- Selected methods / info only – if you select this option, please make your choices from the options that will appear below
- No to all (please note – this may impact on the support we can give you)
Please select methods to contact
- Yes to all phone contact
- Email – yes to all
- Email – yes, but not for generic info as described above
- Text /SMS – yes to all
- Text/SMS – yes, but not for generic info as described above
- Letters – yes to all
- Letters – yes, but not for generic info as described above
This field is hidden when viewing the form
Professional -fields
Your Name (referrer):*
Profession e.g. GP, social worker*
Referrer’s phone number:*
Referrer’s email address:*
Please note – by completing this form you are consenting to Carers of East Lothian holding your professional contact information.We hold this so we can contact you about your referral and provide you with information and updates about our services.
I have the consent of the carer (details below) to make this referral and can confirm that they are aware COEL may contact them. Please note that we CANNOT accept referrals without the carer’s consent.*
- Yes
Carer's Name*
Prefix First Last
Carer's Address*
Street Address Address Line 2 City/Town County Post Code Country
Carer's preferred phone number*
please state no phone number if the carer does not have a phone number
Other phone number
Does the carer have an email address?*
- Yes
- No
Carer’s Email Address*
Carer’s Email Address*
- Carer does not use email
- Unable to obtain email address
Carer's Date Of Birth*
Carer's Gender*
Carer's Ethnic Group*
What year did they become a carer? (A rough estimate is fine)*
Does the carer have any health conditions that impact on their caring role which they have given consent to disclose?
What health condition(s) does the cared-for person(s) have? (You can tick more than one)*
- Autistic Spectrum Disorder
- Dementia or Alzheimer’s
- Drug Addiction
- Alcohol Addiction
- Frail or Elderly
- Learning Disabilities
- Mental Health
- Neurological Condition
- Palliative
- Physical Disabilities
- Sensory Impairment
- Other – please enter in box below
Other
Is cared for person 16 years old or younger?*
- Yes
- No
Is the cared-for person currently in East Lothian Community Hospital?*
(We require this information because we have Hospital Link Workers based in East Lothian Community Hospital.)
- Yes
- No
- Unknown
Which ward?
If known.
Information about the caring role and impact on carer.*
Please DO NOT INCLUDE detailed personal or clinical information about the carer or cared for. Brief information with details relevant to caring role is sufficient (e.g. Mrs X cares for her husband who has dementia. Carer is exhausted from disturbed sleep and cannot leave her husband alone for more than an hour. She has no family nearby to help.)
Reasons for Referral.
Please tick one or more from the following list. For a list of all our services go to: https://www.coel.org.uk/for-carers/our-services/
- Adult Carer Support Plan
- Breaks from Caring Grants (including Time for Me Fund)
- Crisis Grant (including Financial Insecurity Fund) for food, electricity/gas or transport
- Other Grant Funding (including Carers Trust Fund) e.g. for essential equipment or appliances
- Health and Wellbeing support
- Counselling Service
- Social Support e.g. support groups, events, workshops
- Benefit Check and / or help to apply for benefits
- Telephone Befriending
- Hospital Link Carer Support
- Mental Health Carer Support
- Parent Carer Support
- Legal Advice Clinic (info on guardianship, wills, power of attorney)
- Life after Caring (including bereavement support)
- Other (please specify in box below)
Other
Has the carer also been signposted or referred to other support providers?
- Yes
- No
If yes, please list any signposts or referrals which have been made
signposts or referrals which have been made
I consent to Carers of East Lothian holding health information about me and basic health info about the person I care for. We ask for this so we can best support you in your caring role and for our reporting and statistical purposes. If we need to hold more detailed health information in our records about the person you care for, we will seek their permission after discussing this with you first.*
- Yes
- No (please note – this may impact on the support we can give you )
Please read our Privacy Notice which explains how we collect, use and protect your personal data.
For NHS Use only
I am the carer named in this referral. The professional making this referral has explained to me what data Carers of East Lothian requires about me to accept the referral. I understand this will include my contact information and possibly relevant health information relating to me. I consent to this information being shared.
- Yes
- No

Professional -fields

For NHS Use only