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Carer Navigator - Hospital - Professional Support Request(ext)
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Privacy Notice
Before you proceed, we would like to draw your attention to our Privacy Notice.
Your privacy and data protection are of utmost importance to us, and we want to ensure that you are fully informed about how we collect, use and protect your personal information.
Please take a moment to review our privacy notice.
Privacy Policy
Please confirm the following:
I have obtained express consent from the carer being referred to provide all of the information required and request support from Carers Resource.
No
Yes
Status message
We require you to speak to the carer before making this referral, to gain their permission to refer them to the carer service.
Professionals Details
Professionals Details
First Name
Last Name
Job Title
Phone Number
Mobile Number
Email
Professionals Organisation
Professionals Organisation
Please select your hospital and team from the list below
- Choose existing -
AGH Other
AGH SW Team
AGH Wards
BEST Bradford council
Bradford Royal Infirmary
BRI MAID Team
BRI Wards
MAST - Airedale General Hospital
MAST - Bradford Royal Infirmary
Carers Details
Carers Details
First Name
Last Name
Street Address
Street Address Line 2
City
Postcode
Phone Number
Mobile Number
Email
Further Demographics
Date of birth
Gender
Female
Male
Non-binary
Other
Prefer not to say
Other Gender
Is the gender you identify with the same as your sex registered at birth?
Yes
Prefer not to say
No
Ethnicity
Afghani
Arab
Asian / British Asian:Bangladeshi
Asian / British Asian: Indian
Asian / British Asian: Pakistani
Black / Black British: African
Black / Black British: Caribbean
Chinese / British Chinese
Eritrean
Gypsy
Irish Traveller
Kashmiri
Kurdish
Mixed White and Asian
Mixed White and Black African
Mixed White and Black Caribbean
Not Provided
Other: White
Other Asian Background
Other Black Background
Other Ethnic Group
Other Mixed Background
Other White Background
Prefer not to say
Rohingya
Roma
Vietnamese
White Albanian
White and Asian
White British
White Bulgarian
White Croation
White Czech
White East European
White English
White Estonian
White Hungarian
White Irish
White Latvian
White Lithuanian
White Northern Irish
White Polish
White Romanian
White Scottsh
White Slovakian
White Welsh
Other Ethnicity
Sexuality
Bisexual/pansexual
Gay
Heterosexual
Lesbian
Not provided
Other sexual orientation (please state)
Prefer not to say
Too young/undecided
Religion
Agnostic
Anglican (Church in Wales)
Anglican (Church of England)
Anglican (Church of Ireland)
Anglican (Church of Scotland)
Atheist
Baptist
Buddhist
Catholic (Orthodox)
Catholic (Roman)
Christian
Hindu
Humanist
Jehovah's Witness
Jewish
Methodist
Muslim
Non-confirmist
Non-religious
Not Disclosed
Not Known
Other
Pentecostal
Prefer not to say
Presbyterian
Quaker
Rastafarian
Salvationist (Salvation Army)
Sikh
Unitarian
Other Contact Information
Do you consider yourself to have a disability?
- Please select -
No
Not provided
Prefer not to say
Registered Disabled
Yes (Please provide more details)
Is your disability substantial and/or long term?
Substantial
Long-term
Details of your disability
What is your main language?
- Please select -
English
Not provided
Other, please state
Prefer not to say
Other Language
Country of Origin
- Please select -
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas (The)
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Republic of the
Congo, The DR of
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Dijbouti
Dominica
Dominican Republic
East Timor (Timor-Leste)
Ecuador
Egypt
El Salvador
England
Equatorial Guinea
Eritrea
Eswatini
Ethiopia
Fiji
Finland
France
Gabon
Gambia (The)
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Ireland
North Macedonia
Norway
Not known
Oman
Other, please state
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Phillippines
Poland
Portugal
Prefer not to say
Qatar
Republic of Ireland
Romania
Russia
Rwanda
Saint Lucia
Saints Kitts and Nevis
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Scotland
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuala
Vietnam
Wales
Yemen
Zambia
Zimbabwe
Cared For Details
Cared For Details
First Name
Date of birth
Postcode
What is the relationship between the carer and the cared for?
The cared for is the child of the carer
The cared for is the parent of the carer
The cared for is the spouse of the carer
The cared for is the partner of the carer
The cared for is the sibling of the carer
The cared for is the grandchild of the carer
The cared for is the grandparent of the carer
The cared for is the niece or nephew of the carer
The cared for is the aunt/uncle of the carer
Other(Please Specify)
If other please specify in the box below:
If the relationship is not listed above please use this box to specify.
Conditions
Condition
Autistic Spectrum Disorder/ADHD
Brain Injury
Cancer
COVID19
Dementia
Elderly/Frail
Learning Difficulty
Mental Health
Other
Physical Disability
Sensory Impairment
Substance Misuse
Autistic Spectrum Disorder
Asperger Syndrome
Autistic Spectrum Disorder (ASD)
Not specified
Undiagnosed
Pathological Demand Avoidance (PDA)
ADHD
Brain Injury
Aneurysm
Brain Damage
Brain Haemorrhage
Brain Tumour
Cerebrovascular disease
Concussion
Encephalitis
Hydrocephalus
Hypoxic/anoxic brain injury
Not specified
Stroke
Traumatic Brain Injury
Tumour
Cancer
Anal cancer
Bile Duct Cancer (Cholangiocarcinoma)
Bladder cancer
Bone Cancer (Sarcoma)
Bone Marrow Cancer (Myeloma)
Bowel cancer
Brain tumours
Breast Cancer
Cervical
Cervical cancer
Children's Cancers
Colo-rectal
Colon/ Rectal cancer
Endocrine tumours
Eye Cancer (Ocular Melanoma)
Fallopian tube cancer
Gall Bladder Cancer
Head & neck cancers
Kaposi's sarcoma
Kidney
Kidney Cancer
Larynx cancer
Leukaemia
Leukaemia, acute lymphoblastic
Leukaemia, acute myeloid
Leukaemia, chronic lymphocytic
Leukaemia, chronic myeloid
Liver
Liver Cancer
Lung
Lung Cancer
Lymphoma
Lymphoma, Hodgkin
Lymphoma, non-Hodgkin
Melanoma
Mesothelioma
Mouth Cancer
Myeloma
Neuroendocrine tumours
Not specified
Oesophageal Cancer
Other Cancer (see notes field)
Ovarian Cancer
Pancreatic Cancer
Penis Cancer
Prostate Cancer
Pseudomyxoma peritonei
Skin Cancer (Melanoma)
Small bowel cancer
Soft Tissue Sarcomas
Spinal Cord Cancer
Stomach Cancer
Testicular cancer
Throat Cancer
Thymus cancer
Thyroid Cancer
Trachea cancer
Undiagnosed Condition
Unknown Primary Cancer
Vagina cancer
Vulva cancer
Womb (Endometrial) cancer
COVID19
Confirmed case
Unconfirmed case
Dementia
Alzheimer's Disease
Atypical Alzheimer's
Dementia with Lewy Bodies
Frontotemporal Dementia
Korsakoff's Syndrome
Memory loss
Mild Cognitive Impairment (MCI)
Mixed Dementia
Not specified
Vascular Dementia
Elderly/Frail
Confusion
Continence Issues
Falls
Heart problems
Memory problems
Mobility problems
Not specified
Other
Undiagnosed Condition
UTI's
Learning Difficulties
ADD/ADHD
Asperger's Syndrome
Behavioural Problems
Cerebral Palsy
Chromosomal Abnormality
Down's Syndrome
Dyslexia
Dyspraxia
Foetal Alcohol Syndrome
Fragile X Syndrome (FXS)
Genetic Disorder
Global Development Delay
Hydrocephalus
Not specified
Prader-Willi Syndrome
Reactive Attachment Disorder
Undiagnosed condition
Mental Health
Anxiety
Bipolar Disorder
Depression
Eating Disorder
Not specified
Obsessive Compulsive Disorder
Personality Disorder
Phobia
Post Traumatic Stress Disorder
Psychosis
Schizophrenia
Seasonal Affective Disorder
Self Harm
Undiagnosed Condition
Physical Disability
Acondroplasia
Addison's Disease
Allergies
Amputee
Anaemia
Aneurysm
Angina
Ankylosing spondylitis
Arthritis
Asthma
Ataxia
Auto-immune condition (not listed)
Back pain
Bowel Problems
Cauda equina
Cerebral Palsy
Chromosomal abnormality
Coeliac Disease
Colitis
Complex Regional Pain Syndrome
Congenital heart disease
Congenital Myasthenia Syndromes (CMS)
Continence issues
COPD
Crohn's Disease
Cystic Fibrosis
Diabetes
Diverticulitis
Eczema
Ehlers-Danlos Syndrome (EDS)
Encephalitis
Epilepsy
Falls
Fibromyalgia
Gastrostomy/Tube Fed
Genetic disorder
Gout
Guillain - Barre Syndrome
Heart disease
Heart failure
Heart problems
High blood pressure/Hypertension
Huntington's disease
Hydrocephalus
Juvenile idiopathic arthritis
Kasabach Merritt Syndrome ( KMS)
Kidney failure/Kidney disease
Labyrinthitis
Liver failure/Liver disease
Low Blood Pressure
Lung disease/lung problems
Lupus
ME (Chronic Fatigue Syndrome)
Meniere's Disease
Microcephalus
Mitochondrial Disease
Mobility problems
Motor neurone disease (MND)
Multiple sclerosis (MS)
Muscular Dystrophy
Myasthenia Gravis
Myelitis
Narcolepsy
Neurofibromatosis (NF1)
Neurofibromatosis (NF2)
Neurological disorder
Neuropathy
No diagnosis
Not specified
Osteo-arthritis
Osteoarthritis
Osteoporosis
Paget's disease
Pancreatitis
Paralysis
Parkinson's Disease
Perthes Disease
Pierre Robin Syndrome ( or sequence)
Polymyalgia rheumatica (PMR)
Progressive Supranuclear Palsy (PSP)
Psoriasis
Psoriatic Arthritis
Pulmonary Fibrosis
Respiratory problems
Rheumatoid arthritis
Scoliosis
Sjogren's syndrome
Sleep apnoea
Sotos Syndrome
Spina bifida
Spinal injury
Spinal Muscular Atrophy (SMA)
Spinal stenosis
Spondylosis
Systemic sclerosis
Undiagnosed condition
Vasculitis
Wheelchair user
Sensory Impairment
Blind
Deaf
Diabetes Related Eye Conditions
Glaucoma
Hearing Impaired
Macular Degeneration
Nystagmus
Pigmentosa Retinisis
Speech Problems
Tinnitus
Undiagnosed Condition
Visually Impaired
Substance Misuse
(Not specified)
Alcohol
Drug
Solvents
Other
Not specified
Details
Activity
Details of Support Request
Which team is making this referral?
AGH
AGH - MAST
AGH - Other
AGH - SW Team
AGH - Wards
BEST
BRI
BRI - MAID Team
BRI - MAST
BRI - Other
BRI - SW Team
BRI - Wards
Support Request Reference ID
Is the person that the carer is caring for receiving palliative care?'
Is the person that the carer is caring for receiving palliative care?
Urgent
Normal
Low
Please give details of why you are requesting support for this carer
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Lines and paragraphs break automatically.
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Best time to phone
Any time
Morning
Afternoon
Evening (After 5pm)
Is the carer new to caring?
No
Yes
Feedback requested for referral
No
Yes
Case
Case Subject
Case Start Date
Last Name
Assign To Contact Team
Existing Contact
Start Date 3
Relationship to Carers Details Start Date
Relationship to Carers Details Start Date
Activity Subject
All Services - Where did you hear about us?
Airedale Collaborative Care Team(ACCT)
Already known
Bingley Bubble Mini-Hub
CAMHS
Care@
Carer Navigators
Children's Social Care
City Wellbeing Hub(BRI)
Community Development Team
Craven Collaborative Care Team(CCCT)
Early Help
GP
Group Worker
Home from Hospital Bradford
Home from Hospital North Yorkshire
Home from Hospital North Yorkshire - Carers Plus Yorkshire
Information Stand
Keighley Healthy Living
Keighley Pathways Hub
Manningham Mills Wellbeing Hub(ET)
Max Card
New Hub
Newspaper
Other
Other (please give details below)
Other Charity
Other Professional
Radio
School Nurse
School or College
Shipley Wellbeing Hub(Hale)
Social Media
Social Worker
Thornbury Wellbeing Hub(Thornbury Centre)
Tong Wellbeing Hub(Sutton Centre)
Wellbeing Hub
Word of Mouth
Young Carers
Locality worker (at Carers Resource)
All Services - Source
Family or Friends
Professional
Self-Referral
Internal
Advice Line
All Services - Service
Airedale Collaborative Care Team(ACCT)
Bit of a Break
Bradford East Locality
Bradford South Locality
Bradford Statutory Carers Assessment
Bradford West Locality
Care@
Carer Navigators - Community(CNC)
Carer Navigators - Hospital(CNH)
Carers Resource Website
Carers Time Off (CTO)
Caring Callers
Business Processes Team
Business Processes Team Bradford
Business Processes Team Craven
Business Processes Team Harrogate
Business Processes Team Selby
Counselling
Craven Collaborative Care Team(CCCT)
Craven Locality
Development
Groups Team
Harrogate Locality
Home from Hospital Bradford(HfH BD)
Home from Hospital North Yorkshire(HfH NY)
Home from Hospital North Yorkshire - Carers Plus Yorkshire(CPY)
Information Team
Keighley Locality
Locality
Men Care Too
Parent Carers
Selby Locality
Shipley Locality
Single Point of Contact(SPOC)
Supported Discharge
Volunteering
Wellbeing Hubs
Worth Connecting (PROJECT ENDED - DO NOT USE)
Young Carers
Young Carers Bradford
Young Carers Craven
Young Carers Harrogate
Young Carers Selby
Duty Team Bradford
Duty Team North Yorkshire
CReate (PROJECT ENDED - DO NOT USE)
Employment (PROJECT ENDED - DO NOT USE)
Contact Method
Phone (not Duty)
Admin/office work
Carer Registration Card
Email
In Person
In Person (at a group)
In person - At Home (Worth Connecting ONLY)
In person - Other Setting(Worth Connecting ONLY)
Post
Social Media
Duty
Video Call
Webform
Webform(Website}
WhatsApp / Text
Assign To
Existing Contact
Activity 2
Activity Date
Leave this field blank