Dear Referrer,

  • Please read theReferral Criteria and Brief Service informationat the end of this formto ensure that your referral is appropriate.
  • Please select from the ‘Choose an item’ drop down menu to identify your organisation andensure you complete all areas highlighted in red.

Referrers Name:
Name of Organisation:
Telephone: / Email:
Service required (please tick all that apply):
Respite & Befriending
Respite for Healthcare Appointments
SCIPRR (Support for Carers to Plan and Identify Residential Respite)
Computer Help at Home
Carers Wellbeing (Telephone Support/Telephone Counselling)
Carers Companion (Hastings, St Leonards & Bexhill)
Carers Name:
DOB: / Address:
Relationship to Cared for: / Telephone:
Ethnicity: / Sexuality: / Religion:
Carer’s Health (if known)
Carer Risks: Are there any risks identified with the Carer, e.g. stress, etc.
Cared for Name:
DOB: / Address: (if different from Carer)
Cared for Health Condition:
End of Life? (give details) / Telephone:
Cared For Risks: Are there any risks identified with the cared for person, e.g. falls, aggression etc.
Can they use the toilet independently?Yes/No / If no, how is their toileting managed?
Background Information: (Please provide information about the nature and extent of the caring role)
Are there any risks for a lone worker when visiting the residence? Yes/No
If yes please give details:
Please write any information that might be beneficial to us visiting the Carers at home, e.g: pets, general state of the house, smoking, propertyhard to find etc:
Has a Carers assessment been completed? Yes/No Does the Carer have CRESS? Yes/No
In your opinion, how stressed is the carer?
1 2 3 4 5
Not Stressed Moderately Stressed Highly Stressed
How do you feel the carer is coping with their caring role?
1 2 3 4 5
Coping Well Having some difficulties Not Coping
How much support does the carer receive from friends and family?
1 2 3 4 5
Lots of Support Moderate Support No Support
How much support does the carer receive from other agencies?
1 2 3 4 5
Lots of Support Moderate Support No Support
Are they accessing any of the following?
Day Centres ☐Paid Care Workers ☐Other (please state):


Respite and BefriendingFor carers providing substantial levels of care who find it difficult to leave the person they look after, lack support and/or experience high levels of stress and/or social isolation. Respite is usually three hours each week, on the same day, at the same time during which the carer would be able to do whatever they like, as long as it gives them time out from their caring role. No personal care can be undertaken by our volunteers and we would expect a handover between carer and volunteer at the beginning and end of the three hour respite period.

Respite for Healthcare Appointments- Any carer that is already receiving our respite service is eligible to request an additional respite visit to enable them to attend any healthcare appointment. With a minimum of one month’s notice we can also consider supporting any carer (including those not currently receiving our services) who has six or more upcoming health appointments.

Carers Wellbeing Service

  • Talk and Support – A free telephone support service lasting 6 months for Carers who are experiencing loss, isolated or lacking support. We match a volunteer with a Carer, who will then call them at a mutually convenient time so the Carer can discuss in confidence how they are feeling. Phone calls last for up to 30 minutes and are usually weekly, fortnightly or monthly.
  • SCIPRR - Support to identify and plan residential respite for carers needing a longer respite break
  • Telephone counselling – limited service for carers who are experiencing extreme stress

Computer Help at Home - For carers who have a computer, laptop or tablet but lack the skills and confidence to be able to use it. Carers can learn to shop on line, find out information in regard to their caring role and reduce social isolation by learning to use email, skype or social media.

Carers Companion Service - A long-term service only available for carers of people with dementia in the Bexhill area and carers who are caring for people with any condition, in Hastings and St Leonards on Sea. A carefully matched and vetted volunteer will spend time in the carer’s home, or take the carer and the person they look after out (going to the cinema, theatre, garden centre, café etc.). When the person being cared for is uncomfortable accepting a volunteer in the home, the long-term aim is to build a relationship with the volunteer so that the person cared for accepts them and the carer can have some respite time for themselves.

Please note the carer must live at the address as the cared for.

Please return this form to: call us on 01424 722 309