SELF-REFERRAL FORM 
 
A carer is someone who, without payment, provides regular and substantial help and support to a friend, neighbour or relative who could not otherwise manage because of frailty, illness or disability. 
Please use this form to self-refer for Camden Carers services. Complete ALL the details (you and the person you care for) and email it to referrals@camdencs.org.uk 
Tel:   020 7428 8950   
The information will be transferred to our secure electronic database. Do you give consent for your information to be stored on Camden Carers database?
 
Your details 	
Name  	Full Name 	
Date of birth 	Date of Birth 	
Address

	Home Full Address (single line) 

Contact numbers  	Home: Patient Home Telephone 

Mobile: Patient Mobile Telephone 	
Email address	Patient E-mail Address 	
Language spoken	Main Language 	
Interpreter needed? 	 Yes                    No  	
Ethnic origin 	Ethnic Origin 	
Sexuality	     	

How can we help you?

 
 	     	
Details of the person you care for 	
Name 	Patient Carers       
	
Address (if different from carer) 	     	
Relationship to carer 
 	     	
Date of birth 	     	
Any other information 
 
 	     	
Today’s date	     	

Camden Carers is funded by London Borough of Camden and NHS Camden. 
Camden Carers is a registered charitable incorporated organisation 1042757.  
The Greenwood Centre, 37 Greenwood Place, London NW5 1LB