Buckinghamshire Flexible Breaks for Carers
The Flexible Breaks for Carers health fund is for people who provide care, without payment, to someone who is sick or disabled, vulnerable or frail who could not manage without the carer’s help. The fund is aimed at providing a range of breaks to improve the health and wellbeing of carers affected by their caring situation who receive little, if any, support. One fund is available per household. To be considered for the application you must meet all 3 of the following criteria;
- You (carer) or the person you care for has not received support from Buckinghamshire County Council Social Care in the last 12 months e.g.
- Direct payment(s) as a result of a Community Care or Carer Assessment
- Help with personal care
- Respite care such as residential. For carers of children under 18yrs - take-a-break/direct payments for short breaks.
If you are in receipt of services but require more support contact Carers Bucks: 0300 777 2722
- You are caring for 20 hours a week or more.
- You are aged 18 years or over
Details of You (carer):
Title: / Address:
First name:
Surname:
Date of birth:
Telephone:
Mobile:
Email: / Postcode:
Your relationship to the person you care for (e.g. are you their mother, son, friend, partner)
Details of the person you care for:
Title: / Address:
(if different to yours)
First name:
Surname:
Date of birth: / Postcode:
Indicate which disability/health need best describes the person you care for: (tick one box only)
Physical Disability / Learning Disability / Mental health issues
Frail/vulnerable older person / Dementia / Other (please specify)
Please indicate the following:
Risk to my own mental and/or physical health as a consequence of no breaks in my caring role / YES / NO
Risk to continued caring role as a consequence of not taking a break e.g. no other family member or friend able to help out / YES / NO
Name of your GP Practice:
Name of your GP:
GP Practice Address:
Telephone Nº:
Important:
By signing, the carer is confirming that the information provided is accurate andhas given consent for this information to be shared between their GP/health practitioner, County Council and Support Services andfor the data to be anonymised and used for evaluation.
Carer’s Signature / Date
You do not have to provide information below, but it helps us to monitor how effective we are at providing services to carers in Buckinghamshire. Data will be anonymised and used for evaluation of the service only.
Gender:
Male / Female
Ethnicity:
White British / White Other / African
Caribbean / White & Black Caribbean or African / Chinese
Pakistani / Indian / Bangladeshi
Other Asian background / Prefer not to say
Employment Status:
Employed / Unemployed / Retired
Full time carer / On Employment and Support Allowance / Other
Prefer not to say
To be signed by GP or Nominated Health Professional
I believe that the statements and information provided by the carer are accurate and that this carer is registered to this practice
Signature: / Date:
Forms can be emailed or posted to the following;
Email: / Fax: 01296 387155
Post: Flexible Breaks For Carers, Adults and Family Wellbeing,
Buckinghamshire County Council, County Hall
Walton Street, Aylesbury, HP20 1UZ