Register a Carer

We are setting up a register of people who are carers in this community, so that we may help you to access support and information services about being a carer.

All carer’s requirements need to be assessed, in order to do so we need to be able to provide information to Social Services on your behalf.

We are also looking to help you gain access to information for example about rest-bite, support groups, activity centres you can use and funding.

In order to assess what services you have and what services you may need I would be grateful if you could complete the form below.

If you have access to Social Services we would still like you to complete this form for our records.

Register a Carer.

Register a Carer.

If you are human, leave this field blank.

Carer Details

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Address including postcode:

Are you one of the following? (Please tick the appropriate option) *

A parent looking after a disabled child

Looking after a relative

Looking after a friend

A young carer (person under the age of 18 looking after a parent or relative)

What help and support do you presently receive? *

Your GP surgery

Social Services

Financial

Respite

Community Mental Health Team

Case Manager

Carer Support Group

Details of Person Being Cared For

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Address including postcode:

What relation to you is the person being cared for?

Is the person you care for a patient at this surgery?

Yes

No

Is this person any of the following:

An elderly person (+65)

A child (-18)

An adult with a physical disability

An adult with a learning disability

An adult with a mental illness

An adult with a terminal illness

What help and support would you like more information about?

Your GP surgery

Social Services

Financial

Respite

Community Mental Health Team

Case Manager

Carer Support Group

OtherOther

Would you be happy for us to forward your details to Social Services? *

Yes

No