Online Referral Form (Self referral)

  • Lanarkshire Carers Referral Form

  • Please note, not all sections of this form need to be completed to make a referral but any additional information you provide at this stage will be helpful. Certain information must be provided in order for us to deal with your request (*denotes manadatory information).

    You can also make a referral by telephone. Please call us on 01698 428090 or 01236 755550 ensuring you have all of the relevant information.

  • Carers Details

    Please tell us a bit about yourself. The information you provide will allow us to support you effectively.
  •  - -
  • Gender:*
  • Is interpretation required?
  • Do you (the carer) have any health issues?
  •  - -
  • Does the person being cared for have a terminal illness?
  • Are you (the carer) engaging with any other agencies or organisations regarding your caring role?*

  • Referrer Details

    Please tell us a bit more about your referral and how we may support you.
  • Is this a self referral?*
  • Is this a priority referral?*

  • Your Privacy

    Please read this statement carefully and let us know if you are happy for us to store and process your personal information.

  • Lanarkshire Carers will store and process the information provided on this referral form, or any subsequent information provided, in a secure and sensitive manner in line with relevant data protection laws.  This information may be used and shared anonymously with other partner organisations for reporting and monitoring purposes.  Lanarkshire Carers will not disclose any personal information provided with other organisations or individuals without explicit consent, unless a person’s safety and well-being is at risk.  

    Further details on how Lanarkshire Carers uses personal information can be found on our website: www.lanarkshirecarers.org.uk/privacy 

    A printed version of this policy can also be provided on request.

    I (the carer) confirm that I have read and understand this declaration and give consent for my personal information to be stored and processed.  If this referral is being made on behalf of a carer, I (the person making the referral) have explained to the carer how their personal information will be used and obtained their consent to share this information with Lanarkshire Carers.

  • Consent to store and process personal information:*
  • Reload
  • Should be Empty: