This service provides Carers who have suffered an INJURY or developed PAIN during CARING a limited number of sessions for responsive, interim, guidance and relief before universal services can take over. 
Please complete the form below for referral for 
emergency physiotherapy. 

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This service is for Carers living in GLOUCESTERSHIRE, who have developed pain or injury as a result of their caring role and whose condition is not so severe as to need urgent investigation. If your condition gets worse whilst waiting for Physiotherapy then SEE YOUR GP.

IF you are suffering with low back pain and if you have any changes regarding the following since your pain started;
Bladder or bowel function (i.e., Increasing difficulty when you try to urinate, increasing difficulty when you try to stop or control your flow of urine, loss of sensation when you pass urine, leaking urine or recent need to use pads, inabilityof knowing when your bladder is either full or empty, inability to stop bowel movement or leaking, loss of sensation when you pass a bowel motion)
Loss of sensation / tingling around genitals, back passage, buttocks or inner thighs
Erectile or ejaculation problems or loss of sensation in genitals during sexual intercourse
Loss of sensation/ tingling or numbness in both legs • Weakness in foot (i.e. floppy foot or inability to lift front of foot when walking)
If YES call NHS 111 or go to A+E IMMEDIATELY

IF you are suffering with constant pain and if you have any of the following;
History of Cancer; Unexplained weight loss; Feeling generally unwell/ fever/ lack of appetite
Relentless night pain that cannot be relieved by changing position in bed
Please contact with your GP as soon as possible to discuss if other investigations are required rather than self- referring to physiotherapy.

Completing the Form

If you wish to proceed with this self-referral please complete the form fully, giving as much information as possible.
Once you are at the front of the waiting list the physiotherapist will contact you to arrange an appointment for assessment.
Following this appointment a treatment plan will be agreed with you. If your referral is not appropriate for physiotherapy treatment then you will receive an email or phone call advising you to see your GP regarding this problem.
You will be informed when you have been discharged from treatment and will be provided with a summary of your progress.
Please tell us a number that we could contact you on
Please highlight all that apply, hold down the control key and click to select.
Please highlight all that apply, hold down the control key and click to select.
Please give one number as a score for your pain
Please highlight all that apply, hold down the control key and click to select.
Please describe how the injury occurred/when the pain started. Was it sudden or gradual? Describe any pain or limited movement
Please click on the arrow and select your answer
Please give a brief description
If yes please briefly describe them
If yes please give a brief description of how you are affected
Please briefly describe this


The Parent and Carer Alliance C.I.C. is only able to get funding to provide services such as this one, through Grant funders, such as the Carers Gloucestershire Legacy fund and the Gloucestershire Community Foundation.
For funding to continue to be given, the Alliance needs to demonstrate how the support we provide helps families like yours. We need YOUR HELP and FEEDBACK to do this, as telling us what worked for you, helps funders understand why these services are needed


Please click the submit button below to send this form. Once the button is clicked a please wait message should appear, then disappear and be replaced by a thank you message at the TOP of the form. You will then be emailed a copy of the form, showing that it has been submitted.

If this doesn't happen, please scroll up for any error messages, as questions with a red star need to be answered for the form to submit. Any issues click here to contact us
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