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Get Support from a Trafford Carers Centre
Trafford Carers Centre Self Referral Form
Items marked with
*
are required
Carer's Details
*
Carer Address
*
*
*
*
Carer Gender
*
Male
Female
Is it acceptable to you for us to leave a message on your answer machine or with others in the household?
*
Yes
No
Interpreter needed?
*
No
Yes
Cared for Person's Details
*
*
*
Cared for persons needs? (Hold Ctrl to select more than one)
Physical Health
Physical Disability
Dementia
Learning Disability
Mental Health
Enhanced CPA
Standard CPA
Diagnosis
*
Which need or diagnosis causes the greatest concerns?
*
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