Register as a Caregiver If you consider yourself to be an unpaid caregiver living in Gateshead and would like to access support, please complete the form below to register with us. Self-Referral Form – Caregivers Connected Gateshead Your DetailsName(Required) MissMr.Mrs.Ms.Mx.Prof.Rev.Dr. Title First Name Last Name GenderMaleFemaleNon-BinaryIs the gender you identify with the same as your sex registered at birth? Yes No Address(Required) Street Address City Post Code Phone Number(Required)Alternative Phone NumberEmail Address Date of Birth(Required) DD slash MM slash YYYY EthnicityWhite: English, Welsh, Scottish, Northern Irish or BritishAsian, Asian British or Asian WelshArabicBlack, Black British, Black Welsh, Caribbean or AfricanMixed or Multiple ethnic groupsWhite: IrishWhite: Gypsy or Irish Traveller, Roma or Other WhiteOther ethnic groupReligion(Required)No ReligionChristianBuddhistHinduJewishMuslimSikhOther ReligionPrefer not to sayAre you a veteran?(Required)YesNoPrefer not to sayGP Surgery(Required)Beacon View Medical CentreBensham Family PracticeBewick Road SurgeryBirtley Medical GroupBlaydon GP Led Health ClinicBridges Medical Practice, Trinity SquareCentral Gateshead Medical Group, The Health CentreChainbridge Medical PracticeCrawcrook Medical CentreCrowhall Medical Group, Felling Health CentreDr M S Hassan & Partners, South RoadFell Cottage SurgeryFell Tower Medical CentreGlenpark Medical CentreGrange Road Medical PracticeHigh Street Medical CentreHollyhurst Medical CentreLongrigg SurgeryMetro Interchange SurgeryMillennium Family PracticeOldwell Medical PartnershipOxford Terrace Medical GroupPelaw Medical CentreRawling Road SurgeryRyton SurgerySecond Street SurgerySt Albans Medical GroupSunniside SurgeryTeams Medical PracticeThe Grove Medical CentreThe Medical Centre, 1 Rawling RoadWhickham Cottage CentreWrekenton Health CentreGP Out of GatesheadDo you have any health conditions and disabilities?(Required)Do you have any communication needs, including requiring an interpreter?Do you have any allergies?How long have you been a caregiver?How many hours per week do you spend caring?0 to 1516 to 3637 to 80Over 80Emergency Contact DetailsName of Emergency Contact First Name Last Name Relationship to youAuntBrotherChild, Non-BinaryDaughterFatherGrandfatherGrandmotherHusbandMotherSisterSonStep BrotherStep DaughterStep FatherStep MotherStep SisterUncleWifeOtherEmergency Contact Phone NumberEmergency Contact Email Address Emergency Contact AddressThe person you care forName(Required) MissMr.Mrs.Ms.Mx.Prof.Rev.Dr. Title First Name Last Name GenderMaleFemaleNon-BinaryRelationship to you(Required)AuntBrotherChild, Non-BinaryDaughterFatherGrandfatherGrandmotherHusbandMotherPartnerSisterSonStep BrotherStep DaughterStep FatherStep MotherStep SisterUncleWifeOtherAddress(Required) The person I care for lives at my address Street Address City Post Code Date of Birth(Required) DD slash MM slash YYYY EthnicityWhite: English, Welsh, Scottish, Northern Irish or BritishAsian, Asian British or Asian WelshArabicBlack, Black British, Black Welsh, Caribbean or AfricanMixed or Multiple ethnic groupsWhite: IrishWhite: Gypsy or Irish Traveller, Roma or Other WhiteOther ethnic groupReligion(Required)No ReligionChristianBuddhistHinduJewishMuslimSikhOther ReligionPrefer not to sayWhat Health Conditions and Disabilities does the person have?(Required)GP Surgery(Required)Beacon View Medical CentreBensham Family PracticeBewick Road SurgeryBirtley Medical GroupBlaydon GP Led Health ClinicBridges Medical Practice, Trinity SquareCentral Gateshead Medical Group, The Health CentreChainbridge Medical PracticeCrawcrook Medical CentreCrowhall Medical Group, Felling Health CentreDr M S Hassan & Partners, South RoadFell Cottage SurgeryFell Tower Medical CentreGlenpark Medical CentreGrange Road Medical PracticeHigh Street Medical CentreHollyhurst Medical CentreLongrigg SurgeryMetro Interchange SurgeryMillennium Family PracticeOldwell Medical PartnershipOxford Terrace Medical GroupPelaw Medical CentreRawling Road SurgeryRyton SurgerySecond Street SurgerySt Albans Medical GroupSunniside SurgeryTeams Medical PracticeThe Grove Medical CentreThe Medical Centre, 1 Rawling RoadWhickham Cottage CentreWrekenton Health CentreGP Out of GatesheadAccessing SupportWhat services and support would you like to receive from us? Register with Caregivers Connected Gateshead Statutory Carers Assessment Respite Services Support Groups Wellbeing Fund Connecting to Community Networks Information & Advice Emotional Support Benefits Advice Training Courses Newsletter Other Please let us know if there is anything else you would like some support and advice with.How did you find out about us?Gateshead CouncilEducation OrganisationsHealth OrganisationsOther OrganisationWord of MouthOnline Search Engine (via Google, etc.)Social MediaGP PracticeConsent(Required) I agree to the privacy policy.By submitting this form I agree to sharing my information with Carers Federation according to the Carers Federation privacy policy.