Register with Carers Leeds – LYPFT

Carers Leeds and LYPFT share running the Andromeda Carers Group. This group supports carers of people with complex emotional needs/personality disorder.

To help Carers Leeds to contact you about future meetings we need to ask your permission to register you on our database.

If you are already registered with us, there’s no need to complete this form. If you’re unsure, feel free to fill it in and we’ll check for you. If you prefer not to have your details added to our database, you don’t need to take any action.

I’m happy to share my information and have read the Privacy Policy.

I agree

Your Details

What is your first name?

What is your last name?

Address Line 1

Address Line 2 (optional)

City

Postcode

Mobile Telephone Number (optional)

Landline (optional)

Email (optional)

How would you like us to contact you?

Date of Birth

GP Surgery

Ethnic Group

Gender

Sexual Orientation

Are you currently in employment?

Do you require any additional support in communicating?

None

Audio

Braille

BSL

Language (please state below)

Other (please state below)

Additional communication needs (optional)

Your Caring Role

Please tell us briefly about your situation and what you would like help with. This could include information, advice, someone to listen, or putting you in touch with carers who have similar experiences.

What is the main health condition of the person you care for?

What is your relationship to the person you care for?

By clicking ‘send’ you give permission for Carers Leeds to process and store the information that you have given us on our database.
For more information about how we will store and use your information see our privacy statement.