Manchester Carers Centre

CARERS SELF-REFERRAL FORM

Carers needing help and support should fill out our self-referral form below or call our reception line 0161 27 27 27 0 (Monday-Thursday, 10am-1pm). If you can fill out this self-referral form, it helps our staff to process your enquiry more quickly.

    What is your preferred method of contact? TelephoneEmailLetter

    Do you work? Part-TimeFull-TimeNoRetired

    Would you like Information or Assistance with the following? (please tick all that apply)

    Carers AssessmentCarers Trust GrantsTelephone/Email AdviceHealth & Wellbeing Support GroupsInformation on ServicesShort Breaks & Social EventsMembershipTrainingOne To One AppointmentYoung Adult Carers

    Cared For Details

    If you are happy to do so, please provide details of your Cared For below, to help us identify the best kind of support for both you as a Carer and the person you provide care for.

    Please make sure the person you care for has given consent for you to provide their details below.

    Cared For Address

    Do you Care for More Than 1 person? YesNo

    2nd Person Cared For Details

    If you are happy to do so, please provide details of your Cared For below, to help us identify the best kind of support for both you as a Carer and the person you provide care for.

    Please make sure the person you care for has given consent for you to provide their details below.

    Cared For Address

    Summary of your support needs