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Hospital Discharge Grants for Carers
Leave this field blank
Please note: this is a one off grant for carers looking after residents living in the County of Leicestershire and is only applicable to hospital discharges
from 3 February 2025
.
Grant is not to be used for - Hospital visit, outpatients appointments, A&E visits or any other appointments which have no direct relationship with a period of overnight admission to hospital
Referrers details (if applicable - for health and social care professionals to complete only)
Your Name
Surname
Job Title
Place of work
Telephone Number
Email address
Has the carer consented to this referral? Y/N
Cared for Details
Title
Name
Surname
Date of Birth
Gender
Male
Female
Other
Address
Postcode
Telephone Number
Hospital Discharge Details
Has the cared for been discharged from hospital in the last 2 weeks?
Yes
No
If No, please do not complete the rest of the form. For further advice please call Support for Carers on 01858 468543.
Date of hospital discharge
Name of hospital
Ward No.
Hospital address
NHS Number
GP and Name of surgery
Please provide evidence of hospital discharge for example: letter from hospital or other documentation
Carers Details
Title
Name
Surname
Carer date of birth
Carer Gender
Male
Female
Other
Address
Postcode
Telephone
Email
Relationship to the Cared For
Reasons for Hospital Discharge Grant
What conditions and support needs does the cared for person have?
What support are you - the carer, giving to the cared for person on their discharge?
What help and support do you require to look after the cared for person?
Consent to share information
The information you provide will be used for statistical analysis, management and reporting the provision of services provided by the county council and shared with VASL. The information will be held in accordance with the council's records management and retention policy.
Carer Declaration
I certify that the above information is a true record of my current circumstances and that I have not applied elsewhere for the hospital discharge grant. I agree that I will use the funding only for the services detailed on this application. I will retain receipts for 12 months for routine check purposes. If receipts are requested, I will provide within 10 working days of request.
Submit Application
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Support for Carers Leicestershire is funded by
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. However, we rely on donations to enhance the services we provide for carers in the area. If you would like to support us please
contact us
.