Carers Self Assessment

This is a self-assessment form for carers of adults to complete. The information and comments provided will help Adult Social Care Services to identify your needs as a carer and also how the service can help and support you to continue providing care for the person you look after.

A simple definition of a Carer is:

“A Carer is a person who offers substantial and regular care to someone, who without it could not manage their daily living.”

Please complete all relevant sections.

Carer's Personal Details

Your Full Name

Title
If Other, please specify
First name(s) ^*
Surname ^*

Usual Address

Prefix e.g. first floor flat.
House name/number
Street
Village/Area e.g. Scawby, Bottesford, etc.
Town
County
Post code ^*Please input your post code using capitals and include a space between the first and second parts e.g. DN17 5TY.

If you have provided a valid email address you will automatically receive a copy of your completed form when submitted.

Date of Birth ^*

NHS Number (if known) Please enter with no spaces (e.g. 1234567890)

Relationship to the person they care for ^*

Ethnicity:

White

British

Irish

Other white background (see below)

If other please specify

Mixed

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background (see below)

If other please specify

Black or Black British

Caribbean

African

Any other black background (see below)

If other please specify

Asian or Asian Background

Indian

Pakistani

Bangladeshi

Any other asian background (see below)

If other please specify

Chinese or other ethnic group

Chinese

Other ethnic group (see below)

If other please specify

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