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, ensuring you have all of the relevant information.

Lanarkshire Carers Centre 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 the Data Protection Act.  This information may be used and shared anonymously with other partner organisations for reporting and monitoring purposes.  Lanarkshire Carers Centre will not disclose any of the information captured with other organisations or individuals without the carers consent unless the person’s safety and well-being may be affected.  

For further guidance on how personal information should be handled can be found on the Commissioner’s Office website: www.ico.org.uk

I (the carer) confirm that I have read and understand this declaration and give permission for my personal information to be stored.  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 permission to share this information with Lanarkshire Carers Centre