(* denotes mandatory fields
)
Data sharing consent
In order to support you we need to know some personal information about you and the person you care for, including how we can contact you about services. We need this information to ensure our services and those that other agencies offer you, meet your needs.
We may share information with organisations who fund us, including the local authority and the NHS. Further details of how we handle your personal information can be found on our website.(
Carers in Bedfordshire
Privacy Policy
).
Are you happy for us to proceed with registering you the
Carer / Person affected by memory loss or dementia
with Carers in Bedfordshire on this basis?
Yes
No
Date of consent
Registration details
Person completing form
Person affected by memory loss or dementia
Carer
Other
Professional
Register the PMD's Carer?
Yes
No
Does PMD look after someone who can't manage without them?
Yes
No
Hidden fields
Account Id
Status
User ID
Submission Form
Refresh Locality
Yes
Person affected by Memory Loss or Dementia
Test Records
Test Record?
Please select...
Yes
No
Test Mode
Form is in Test mode - New Referral notifications are sent to the Test Support Worker user
Title
Mr
Mrs
Miss
Ms
Dr
First Name
Surname
Preferred name
Date of birth (dd/mm/yyyy)
Gender
Male
Female
Other
In Law only?
Please select...
Yes
No
Address
Country
Postcode
Town / City
Street
Preferred number
Home
Mobile
Mobile number
Home phone
Home phone
Mobile number
Email address
Preferred contact method
Home phone
Work phone
Mobile phone
Email
Post
SMS
No Contact
Marketing Communications
Occasionally we may wish to contact you with information on the charity’s broader activities and services. This may include Carers Discount Card offers, job and volunteering opportunities, fundraising activities.
Are you happy to receive information that we believe will interest you on topics like these?
Marketing contact?
Yes
No
Email opt in
Yes
No
Home phone opt in
Yes
No
Mobile phone opt in
Yes
No
Post opt in
Yes
No
SMS opt in
Yes
No
Preferred contact method(s)
Ok to contact by home phone?
Yes
No
Ok to contact by mobile phone?
Yes
No
Ok to contact by email?
Yes
No
Ok to contact by post?
Yes
No
Ok to contact by sms (text message)?
Yes
No
Ok to leave message on home voicemail?
Yes
No
Ok to leave message on mobile voicemail?
Yes
No
OK to leave message with someone else and If so, who?
Memory concerns/diagnosis info
If primary diagnosis is dementia, which form?
Alzheimers Disease
Vascular Dementia
Mixed Dementia
Lewy Bodies
Frontotemporal
Mild Cognitive Impairment
Not known
Other
No diagnosis
When diagnosed if known (mm/yyyy)
If Carer giving data, is person aware of the diagnosis?
Please select...
Yes
No
Register PMD with navigation service?
Please select...
Yes
No
Person affected by Memory Loss or Dementia
Monitoring
GP name
GP Surgery
Please select...
Ampthill Road Surgery, Bedford
Arlesey Surgery
Ashburnham Road Surgery, Bedford
Asplands Medical Centre, Woburn
Barton Hills Surgery Luton
Barton-le-Clay Surgery
Bassett Road Surgery, Leighton Buzzard
Bell House Medical Centre Luton
Biggleswade Health Centre
Bramingham Park Medical Centre Luton
Britannia House Surgery Luton
Bushmead Avenue Surgery, Bedford
Bushmead Medical Centre
Bute House Medical Centre Luton
Caddington Surgery, Luton
Castle Street Surgery, Luton
Cater Street Surgery, Kempston
Cauldwell Medical Center
Church Street, Langford
Clapham Road Surgery Bedford
Conway Medical Centre
Cranfield and Marston Surgery
Cranfield Surgery
De Parys Bedford Medical Practice
De Parys Bromham Medical Practice
De Parys Oakley Medical Practice
Dr A Zaman's Practice
Eastgate Surgery, Dunstable
Edlesborough Surgery, Dunstable
Eleanor Close Surgery, Woburn
Farley Hill Medical Centre
Fields Road Surgery, Wootton
Gardenia Surgery
Goldington Avenue, Bedford
Goldington Road Surgery, Bedford
Great Barford Surgery
Great Denham Village Surgery
Greensand Surgery / The Health Centre, Ampthill
Greensands Medical Practice / Brook End Surgery, Potton
Grovebury Road Surgery, Leighton Buzzard
Harrold Medical Practice
Highlands Surgery, Flitwick
Hockwell Ring Medical Practice (luton CCG)
Houghton Close Surgery, Ampthill
Houghton Regis Medical Centre
Ivel Medical Centre, Biggleswade
King Street Surgery, Kempston
Kingfisher Practice
Kings Road Surgery, Sandy
Kingsbury Court Surgery, Dunstable
Kingsway Health Centre
Kirby Road, Dunstable
Langford Surgery
Lansdowne Road Surgery, Bedford
Larksfield Surgery
Larkside Practice
Lea Vale Medical Group
Leagrave Surgery
Leighton Road Surgery
Linden Road Surgery, Bedford
Lister House Surgery
London Road Health Centre, Bedford
Medici Medical Practice
Medina Medical Surgery
Moakes Medical Centre
Neville Road Surgery
Oakley Surgery
Oliver Street Surgery
Pemberley Surgery, Bedford
Priory Gardens Health Centre, Dunstable
Priory Medical Practice, Clapham
Putnoe Medical Centre / NHS Walk-in Centre, Bedford
Queens Park Health Centre, Bedford
Rothsay Surgery, Bedford
Salisbury House Surgery
Sandy Health Centre, Sandy
Shakespeare Road Surgery, Bedford
Sharnbrook Surgery
Shefford Health Centre
Shortstown Surgery
St John's Street, Kempston
Station Road, Lower Stondon
Stopsley Village Practice
Sundon Medical Centre
Sundon Park Health Centre
Templars Way Surgery, Sharnbrook
The Health Centre, Luton
The Link Surgery
The Medical Centre, Bedford
The Village Medical Centre, Great Denham
Toddington Medical Centre
Town Centre GP Surgery
Tyne Crescent Surgery, Bedford
Victoria Road Surgery, Bedford
Wenlock Surgery
West Street Surgery, Dunstable
Wheatfield Surgery, Luton
Whipperley Medical Centre
Wilstead Branch Surgery
Woodland Avenue Practice
Wootton Vale Healthy Living Centre, Wootton
Out of Area GP Surgery
Other / Undisclosed
Communication requirements
Ethnic origin
Please select...
Arab
Asian or Asian British Bangladeshi
Asian or Asian British Indian
Asian or Asian British Other
Asian or Asian British Pakistani
Black or Black British African
Black or Black British Caribbean
Black or Black British Other
Chinese
Irish gypsy and traveller
Mixed Other
Mixed White/Asian
Mixed White/Black African
Mixed White/Black Caribbean
White British
White Irish
White Other
Any other ethnic group
How heard about the Memory services?
Please select...
Memory Assessment Service
Alzheimers Society
GP
Leaflet/advert/poster
Tibbs Dementia Foundation
Social Worker/Social Care
Family member/friend
Other
Additional information about how PMD heard about Memory services
Employment status
Please select...
Not working
Employed fulltime
Employed part-time
Self employed
Long term health condition or disability?
Yes
No
Details of long term health condition or disability
PMD Other information
Years caring
Months caring
Do you live alone?
Yes
No
If PMD giving data, does anyone in your family help you?
Yes
No
Not Used - PMD Other information
Any other Carers in household?
Yes
No
If yes, are they under 18?
Yes
No
Please list ALL persons who live in the household (i.e. same address)
Are there any risks that we need to be aware of?
Yes
No
If so, what risks?
PMD Notes
Referral information
Carer of the person affected by memory loss or dementia
Title
Mr
Mrs
Miss
Ms
Dr
First Name
Surname
Date of birth (dd/mm/yyyy)
Carer Type
Adult Carer
Dementia / Memory Loss Carer
Young Carer 4-15yrs
Young Carer 16-17yrs
Sibling Carer 4-17yrs
Young Adult Carer 18-25 yrs
Parent Carer
Veteran Carer
Former Carer
Unknown
Relationship to the person with memory loss or dementia
Please select...
Adopted Son
Aunt
Brother
Child (Undisclosed Sex)
Cousin
Daughter
Ex Partner
Father
Foster Daughter
Foster Son
Friend
Grandchild
Grandfather
Grandmother
Great-Grandfather
Husband
Mother
Neighbour
Nephew
Niece
Other
Parent (Undisclosed)
Partner
Sibling
Sister
Son
Step Daughter
Step Father
Step Son
Uncle
Wife
Home phone
Mobile number
Preferred number
Home
Mobile
Email
Marketing Communications
Occasionally we may wish to contact you with information on the charity’s broader activities and services. This may include Carers Discount Card offers, job and volunteering opportunities, fundraising activities.
Are you happy to receive information that we believe will interest you on topics like these?
Marketing contact?
Yes
No
Email opt in
Yes
No
Home phone opt in
Yes
No
Mobile phone opt in
Yes
No
Post opt in
Yes
No
SMS opt in
Yes
No
Preferred contact method(s)
Ok to contact by home phone?
Yes
No
Ok to contact by mobile phone?
Yes
No
Ok to contact by email?
Yes
No
Ok to contact by post?
Yes
No
Ok to contact by sms (text message)?
Yes
No
Ok to leave message on home voicemail?
Yes
No
Ok to leave message on mobile voicemail?
Yes
No
OK to leave message with someone else and If so, who?
Carer Gender and DOB
Gender
Male
Female
Other
Address
Same address as the person affected by Memory Loss or Dementia
Yes
No
Country
Postcode
Town / City
Street
Register Carer for Memory / Dementia services or all Carer support services
Memory / Dementia only
All
Carer All Services
Carer Information preferences
Would you like to receive information on services including our quarterly magazine, Carers?
Email
Post
Email and Post
NIL by Post
How would you like to be reminded about appointments?
Post
Email
SMS
Carer Other support
Receiving other support?
Yes
No
Other support agencies
Please list ALL known organisations involved with the family
Carer Monitoring
GP name
GP Surgery
Please select...
Ampthill Road Surgery, Bedford
Arlesey Surgery
Ashburnham Road Surgery, Bedford
Barton-le-Clay Surgery
Bassett Road Surgery, Leighton Buzzard
Biggleswade Health Centre
Bushmead Avenue Surgery, Bedford
Caddington Surgery, Luton
Cater Street Surgery, Kempston
Church Street, Langford
Clapham Road Surgery Bedford
Cranfield and Marston Surgery
De Parys Bedford Medical Practice
De Parys Bromham Medical Practice
De Parys Oakley Medical Practice
Eastgate Surgery, Dunstable
Eleanor Close Surgery, Woburn
Fields Road Surgery, Wootton
Goldington Avenue, Bedford
Goldington Road Surgery, Bedford
Goldington Road Surgery, Bedford
Greensand Surgery / The Health Centre, Ampthill
Greensands Medical Practice / Brook End Surgery, Potton
Grovebury Road Surgery, Leighton Buzzard
Harrold Medical Practice
Highlands Surgery, Flitwick
Houghton Regis Medical Centre
Ivel Medical Centre, Biggleswade
King Street Surgery, Kempston
Kings Road Surgery, Sandy
Kirby Road, Dunstable
Lansdowne Road Surgery, Bedford
Larksfield Surgery
Linden Road Surgery, Bedford
London Road Health Centre, Bedford
Pemberley Surgery, Bedford
Priory Gardens Health Centre, Dunstable
Putnoe Medical Centre / NHS Walk-in Centre, Bedford
Queens Park Health Centre, Bedford
Rothsay Surgery, Bedford
Sandy Health Centre, Sandy
Shefford Health Centre
St John's Street, Kempston
Station Road, Lower Stondon
Templars Way Surgery, Sharnbrook
The Health Centre, Luton
The Medical Centre, Bedford
The Village Medical Centre, Great Denham
Toddington Medical Centre
Tyne Crescent Surgery, Bedford
Victoria Road Surgery, Bedford
West Street Surgery, Dunstable
Wheatfield Surgery, Luton
Out of Area GP Surgery
Communication requirements
Ethnic origin
Please select...
Arab
Asian or Asian British Bangladeshi
Asian or Asian British Indian
Asian or Asian British Other
Asian or Asian British Pakistani
Black or Black British African
Black or Black British Caribbean
Black or Black British Other
Chinese
Irish gypsy and traveller
Mixed Other
Mixed White/Asian
Mixed White/Black African
Mixed White/Black Caribbean
White British
White Irish
White Other
Any other ethnic group
Carer Years and Months caring
Years caring
Months caring
Religion / faith
Please select...
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Other
None
How heard about CIB
Please select...
Leaflet
Internet
Friend or family member
GP
Social worker
Other organisation / individual
Additional information about how Carer heard of CIB
Employment status
Please select...
Not working
Employed fulltime
Employed part-time
Self employed
Long term health condition or disability?
Yes
No
Details of long term health condition or disability
Sexuality
Please select...
Hetrosexual
Lesbian gay or bisexual
Prefer not to say
Professional Referrer details
Professional
Referrer name and organisation
First name
Surname
Organisation
Preferred contact method
Home phone
Work phone
Mobile phone
Email
Post
SMS
Home Phone
Mobile Number
Email
Mobile Number
Email
Home Phone
Email
Home Phone
Mobile Number
Email
Mobile Number
Home phone
Mobile Number
Home Phone
Email
Preferred contact method(s)
Ok to contact by home phone?
Yes
No
Ok to contact by mobile phone?
Yes
No
Ok to contact by email?
Yes
No
Ok to contact by post?
Yes
No
Ok to contact by sms (text message)?
Yes
No
Contact before PMD / Carer?
Yes
No
Does PMD / Carer know you have asked us to contact them?
Yes
No
Professional Referrer's assessment of PMD / Carer's needs
Not used
Referral source
Referral source
Bedford
Bedford Lounge
Biggleswade
Leighton Buzzard
Luton Lounge
Other
Source if other
Welcome pack sent
Yes
No
Relationship Support
Budgeting
Yes
No
Domestic
Yes
No
Emotional
Yes
No
Medical
Yes
No
Personal
Yes
No
Moving
Yes
No
Schooling/College
Schooling/College headline information
School/College Name Known?
Yes
No
School/College Contact Person Known
Yes
No
School Attendance? (%)
School aware of referral?
Yes
No
NEET or risk of NEET?
Yes
No
School/College Contact Details
School/College Name
Title
Mr
Mrs
Miss
Ms
Dr
Other Salutation
First Name
Surname
Preferred Name
Contact Number
School/College Address
Street
Town / City
Postcode
Country
Please select...
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
More information about Young Carers
Has a CAF/EHA been completed?
Yes
No
Is the person on a CP/CIN/TAF?
CP
CIN
TAF
Something similar
None
Is the young carer the main carer?
Yes
No
Would other identified carers like support?
Yes
No
Does the carer care for a sibling?
Yes
No
If so, does the parent receive support?
Yes
No
Are the family aware of this referral?
Yes
No
Do you have verbal/written consent for this referral from the parents?
Yes
No
Does the young person have difficulties in any of the following areas?
Education/work
Yes
No
Isolation/friendships
Yes
No
Safeguarding issues
0 - No risk
1 - Cause for Concern
2 - Incident
3 - SOVA
Housing
Yes
No
Behaviour
Yes
No
Mental Health/self-esteem
Yes
No
Physical health
Yes
No
Understanding disability
Yes
No
Consent
Consent given for the following
Basic first aid
Emergency medical treatment
Media use and promotion inc social media
Receiving text messages
Transported in private car or taxi
Verbal/Written consent for this referral from parent
Person Completing this form - Other
First Name
Last Name
Date of birth (dd/mm/yyyy)
Phone Number
Email
Thank You!
It looks like we already have your details - contact us if you want to update your records or are you need further support.
Please contact us on
contact@carersinbeds.org.uk
or call us on
0300 111 1919.
id
Consent Required
In order for Carers in Bedfordshire to support you we need you to consent to us using your data as described in our privacy policy. To continue with our registration you must select Yes. For further information please call us on 0300 111 1919.
Existing record?
Please select...
Yes
No