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Self Referral Form

The information you supply here is voluntary, the more information you supply us with, the more we can tailor our support.

Personal Information – Information About Carer

 
 

If you indicated some or lots above, please detail how you consider your caring role has impacted on you. Please choose all that apply.

If you are not currently registered with Shetland Carers, please provide details of someone who can confirm your caring role e.g. family member / health professional / social worker

Information About Person Being Cared For

This section relates to the CARED FOR PERSON. Please choose the correct statement which applies:

Please provide the following information about the CARED FOR PERSON:

**As a minimum, we require the NAME of the cared for person**

 

What is the illness/condition/disability of the person you care for? Please choose all that apply.

Can you please let us know where you heard about Shetland Carers?

Data Protection

Shetland Carers have a legal requirement to submit a Carers Census Return to Scottish Government on an annual basis. All data provided is anonymised. The information which we request in this form is in line with this.

Here at Shetland Carers/Voluntary Action Shetland (VAS) we take your privacy seriously and will only use your personal information to administer your account through our database, to provide the products and services you have requested from us and from time to time to share information relating to the service we provide. In order to provide carers with a better service we are now working in partnership with Shetland Care Attendant Scheme (SCAS) where we will share your information with this organisation via a joint database. If you have any concerns about this please discuss this with us.

Where appropriate, and with your consent, we will liaise with a range of other partners to support you in your caring role.

Please indicate your preferred method(s) of communication:

Throughout the year we would like to send you our quarterly newsletter to provide information relating to our service. Please tick if you agree to us providing you with a copy of our newsletter. You can unsubscribe from receiving our newsletter at any time.

Shetland Carers aligns with the Shetland Child and Adult Protection Procedures and we may need to pass on information where it is deemed necessary to do so.

I HAVE READ THE INFORMATION ABOVE AND I CAN CONFIRM THE DETAILS ARE CORRECT.
I HAVE READ AND UNDERSTOOD AND AGREE TO THE DATA SHARING NOTIFICATION.

I AM EITHER:
THE LEGAL PARENT/GUARDIAN OF A CHILD UNDER 16 AND GIVE CONSENT FOR THEIR INFORMATION TO BE SHARED
OR
I HAVE OBTAINED CONSENT FROM THE CARED FOR PERSON (OVER 16 YEARS) TO SHARE THEIR INFORMATION
OR
THE CARED FOR PERSON (OVER 16 YEARS) DOES NOT HAVE CAPACITY TO CONSENT. I AM THEIR POWER OF ATTORNEY AND GIVE CONSENT FOR THEIR INFORMATION TO BE SHARED
OR
THE CARED FOR PERSON (OVER 16 YEARS) DOES NOT HAVE CAPACITY TO CONSENT. I HAVE OBTAINED CONSENT FROM THEIR POWER OF ATTORNEY FOR THEIR INFORMATION TO BE SHARED.

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