Carer Registration Form
YOUR DETAILS
Title:…………..First Name:………………….………………………....Surname: ……..…………………………………………………………………
Date of Birth:…………………...... Preferred name: …….………………………………………………………..
Gender (circle):Male/Female Any communication needs: ………………………………………………………………………….……….
Address:……………………………………………………………………………………………......
Postcode:………………………………………………………………………Email address:………………………..………………………………………
Landline Number:………………………………………………………….Mobile Number:……………......
Preferred Contact Method: Post Email Phone Mobile
Employment Status: Full time/Part-time/Self-employed/Retired/Student/Unemployed/Gave up work to care
Average hours care provided each week (include overnight hours):
Up to 4 5-19 20-34 35-49 50+
How long have you been providing care?
Less than 1 year 1-4 years 5-9 years 10-19 years 20+years
Does your caring role impact on your:
Physical health? Yes/No How?......
Mental health? Yes/No How?......
Emotional wellbeing? Yes/No How?……………………………………………………………………………………………………………………..
Your Health problems: …………………………………………………………………………………………………………………………………….……
………………………………………………………………………………………………………………………………………………………………………………...
Are there any young people in your home aged 16 or under helping to provide care?
Yes No
Your GP Practice: …………………………………………………………………..…………………………………………………………………………………..
EQUALITY + DIVERSITY MONITORING (Leave blank anything you do not wish to share)
Sexual Orientation:………………………………………………………..Ethnicity:………………………………………..……………………….……
Nationality:…………………………………………………………………….First Language:……………………………………………………………..
Interpreter Required:Yes No Religion:…………………………Marital Status: ……………………..
REFERRAL DETAILS Referred by: Self Agency
How did you hear about Quarriers?......
Referrer name:…………………………………………………………………Organisation:………………………………….……………….…………
Contact Address:…………………………………………………………………......
Contact Number:…………………………………………...... Email:……………………………......
DETAILS OF THE PERSON YOU CARE FOR
Name:………………………………………………………………………………Date of Birth:……………………………………………………….…..
Address (if different from above):………………………………………………………..………………......
…………………………………………………………………………………………......
Contact number:……………………………………….…………………….Relationship to carer:……………………………………….………
Gender: Male/Female Religion: ……………………………………Ethnicity: ………………………………………………………………….
Consent to share their details? Yes No Does not have capacity
Details of Health/Medical issues:
(e.g. Frail/Elderly/Dementia/Physical or Learning Disability/Substance Misuse/Mental Health/Epilepsy/condition etc)
……………………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………………..
Services currently involved in supporting you and/or the person you care for:
District Nurse/Day Care/Health Visitor/Respite/Home Care/other
Detail of other services:………………………………………………………………………..…………..…………………………………..……………
………………………………………………………………………………………………………………..……………………………………………………………
Do you care for more than one person? Yes No
If yes, please providefurther details (e.g. name, address, date of birth, condition, supports in place):
……………………………………………………………………………………………………………………………………......
…………………………………………………………………………………………………………………………………………………………………………….
Sharing information
Quarriers are members of the Carer Service Provider Network (Moray), whose members share information to reduce duplication and make delivery of information and resources more effective. With your agreement, we will enable mailings from relevant CSPN members. Your information will remain confidential between Network members.
Agree Disagree
Data Protection
All records relating to Carers we support are held in accordance with the Data Protection Act (1998). We are committed to ensuring all personal date is accurate, stored securely and accessible to you on request. Full details of how Quarriers manages people’s personal data are outlined in the Data Protection and Archiving Standard, which you can access on request.
I agree that Quarriers stores my information in accordance with the above statement
Signature ...... Date ......
I agree/do not agree (delete as appropriate) that my information may be shared with agencies involved in the provision of services for myself and the person I care for
Signature ...... …………..Date......
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Carer Registration Form March 2018