If you would like to refer yourself to Crossroads to be assessed for a support service to you, a friend or family member, please complete the Self Assessment Form with the basic information we will need and a member of our Care Management Team will contact you within 48 hours of receipt of the form. Please send the form to your closest Crossroads Care scheme office.

Carer Name
Name of the Person with Care Needs
Date of Birth
Address
Home Phone
Work Phone
Mobile Number
Relationship
?
Relationship to person with care needs
Email Address
Preferred / first language
Length of time caring?
How did you hear about Crossroads?