Cookie	Purpose	Expiry
cookie-popup	Keeps track of whether you choose to 'Use necessary cookies' or 'Allow all cookies'	1 year

Cookie	Purpose	Expiry
accessibility-controls	Records option regarding additional cookies.	End of browsing session
saveFontSize	Allows the website (CMS) to record if the user’s font size selection.	End of browsing session
contrast-mode	Allows the website (CMS) to record the user’s contrast mode selection.	End of browsing session
googtrans	Allows the language of page content to be changed and records the language selected.	End of browsing session

Cookie	Purpose	Expiry
_ga	Distinguishes user for Google Analytics.	2 years
_gid	Distinguishes user for Google Analytics.	1 day
_gat	Throttles request rate for Google Analytics.	1 minute
_ga_0PGJBNHYNB	Persists session state for newer versions of Google Analytics.	2 years
__utma	Distinguishes user and session for Google Analytics.	2 years
__utmb	Determines new session or visit for Google Analytics.	30 minutes
__utmc	Determines new session or visit for Google Analytics.	End of browsing session
__utmz	Stores traffic source for Google Analytics.	6 months

Cookie	Source	Purpose	Expiry
CONSENT	YouTube (.youtube-nocookie.com)	Google cookie tracking consent with analytics and/or ad integration.	2 years
CONSENT	Google Maps (.google.com)	Google cookie tracking consent with analytics and/or ad integration.	2 years
__cf_bm	Vimeo (.vimeo.com)	Vimeo ClouldFlare layer which filters out requests from bots.	30 minutes

Cookie	Source	Path	Purpose	Expiry
_GRECAPTCHA _grecaptcha	Google (www.google.com)	/recaptcha	Provides risk analysis to Google spam protection.	6 months

Check in & Chat Service for Carers Self-Referral Form

Check in & Chat is not a clinical, counselling, or crisis service.

Central and North West London NHS Trust provide a free telephone service for Carers where you are matched with a trained volunteer who is someone who can be there just for you; to listen to you and give you some time when you most need it. They will work at your pace and offer non-judgemental support for an eight-week period.

Section 1 – All about You

1. Date Required

2. Your Full name Required

3. Your Date of Birth? (carer’s DOB) Required

4. Address Required

5. Phone Number Required

6. Email

7. NHS Number Required

8. Please tell us why and what you would like to achieve from the Check-in & Chat service? (Reasons could be: feeling lonely; needing someone to talk to) Required

9. Please provide your current GP surgery, GP phone number and GP email. Required

10. Do you give consent to us notifying your GP that you are receiving support from Check in & Chat? Required

Yes

Check in & Chat is Trust-wide which means we operate in any of the boroughs and areas that CNWL covers. The service is open to Carers who are over the age of 18 that are not (current) service users themselves.

Section 2 – About the Person you care for

11. Please provide the full name of the person that you care for. Required

12. Do you know their NHS number so we can find them on our system? If yes, please provide it below. Otherwise, please leave this blank

13. Please provide the Date of Birth of the person that you care for. Required

14. What is your relationship to the person? For example, are you their mother, brother, son, friend? Required

Section 3 – Which of the following best describes you

15. Gender Required

16. Ethnicity, Nationality and Cultural Details (Please select from the drop down list) Required

17. Sexual Orientation (Please select from the drop down list) Required

18. If you have selected 'Other' for question 17, please specify

19. Religion / Spiritual Group (Please select from the drop down list) Required

20. Marital Status

21. Occupation

22. Disability Status (Please select from the drop down list)

I understand that Check in & Chat is a listening service and does not provide clinical, crisis advice or counselling Required

Yes, I understand

I agree to the privacy policy

Check in & Chat Service for Carers Self-Referral Form

Section 1 – All about You

Section 2 – About the Person you care for

Section 3 – Which of the following best describes you

Accessibility tools