Carers Self Referral Form

Please complete the fields below...

Once WIRED receive this referral a staff member from the Wirral Carers Health and Wellbeing Service delivered by WIRED will contact you to offer free information, advice and support relating to your caring role. Information on training, access to local support groups, carers benefits information etc will also be provided. You will also have the opportunity to be registered with WIRED on the Wirral Carers Register in order to receive regular e news bullet ins relating to unpaid carers.

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* 1. Full name

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* 2. Email address

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* 3. Mobile/landline number

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* 4. First line of address and post code (this is so we can send out a carers pack to yourself containing a registration form and all of our information to help support you)

Address

ZIP/Postal Code

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* 5. Where did you find out about us?

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* 6. Would you like to receive your Carers Registration form Online or via Post?

Online (sent on a link via email)

Post (send the form out to you by post for you to send back to us in a prepaid envelope)