Carers Assessment Form

CARERS ASSESSMENT FORM

Please note: this form is to be completed by social services in conjunction with the carer.
CARERS DETAILS
Title:
First Name:
Surname: / DOB: or Age:
Ethnicity: / Gender:Female Male
Address: / Postcode:
Email Address: / Phone No:
What is your relationship to the person you care for?
Name of GP:
ABOUT THE PERSON YOU CARE FOR
Cared For Person’s Name: / DOB: or Age:
Social Services ID (If known):
Ethnicity: / Gender:Female Male
Address: / Postcode:
Email Address:
Care Group of Person: (Check boxes here to be here) / Phone No:
Has the person had a community care assessment?
Yes No
If ‘No’ can you give a reason for this?

Is there anything we can do to make communication easier during theassessments?

Yes No
Details:
HOUSEHOLD TASKS
A)I always have difficulty in finding any time to undertake household tasks.
B)I often have difficulty in finding any time to undertake household tasks
C)I sometimes have difficulty in finding time to undertake household tasks.
D)I do not need help around the home.
Details:
HAVING A BREAK
A)I am unable to take any time off from my caring role
B)I am ble to take time off now and again but not on a regular basis
C)I am able to take time off as and when I need to.
D)I am happy with my caring role and currently do not feel the need to time off.
Details (For example reasons why breaks can’t be taken; what type of break is required; support required in order to take a break):
WORK AND LEARNING
A)I have had to stop working/studying/volunteering to carry out my caring role but would like to return to full time/part time/a few hours
B)I have had to reduce my work/study hours due to my caring role
C)I study/work full time and combine my caring role
D)Study/work/volunteering is not important to me
Details:
Hasadditional support/adviceconcerning employment/volunteering or education?
Yes No
Details:
RELIGIOUS FAITH
A) I am unable to observe my religious faith at all.
B) I am mostly able to observe my religious faith if I wish to.
C) I can observe my religious faith when I wish to.
D) Religious faith is not important to me.
Details:
AMOUNT OF SUPPORT
A)I provide an INTENSIVE amount of support.
A)I provide a SIGNIFICANTlevel of support
B)I provide a MODERATE amount of support
C)I provide a LOW amount of support
What do you do for the person you care for?
OTHER CARING SUPPORT
A) I am the only person providing care
B) I provide the majority of care but have support from one other person
C) I share caring responsibilities with one or more people
D) I provide support to assist another carer
Does the person get help from anyone else (inc organisations)?
Yes No
If ‘Yes’ Details
EMERGENCIES
Do you feel you have enough help if you needed to take a break from caring at short notice (for example if you were unwell)?
Do you wish to be referred on to the Carers Emergency Respite Scheme?
Yes No
Date papers sent:
Maintaining your own health and wellbeing
A)I am a full-time unpaid carer and my caring role has a CRITICAL impact on my life and well-being
B)I am a full-time unpaid carer and my caring role has a SUBSTANTIAL impact on my life and well-being
C)My caring role has SOME impact on my life and my well-being
D)My caring role has LITTLE or NO impact on my life and well-being.
E)The person I care for is supported 24 hours, 7 days per week by paid carers
Details (For example disabilities or health problems; impact on getting enough sleep):
Do you have any health problems that are directly affected by your caring role?
Do you feel your safety is at risk in any way?
RELATIONSHIPS
Do you feel that being a carer has affected your relationship with the person you care for?
Do you feel that being a carer has affected your relationship with others?
Do you have other family responsibilities that are affected by caring?
Space and Equipment
Do you have equipment to help with caring (including Telecare?
Do you have any difficulties with equipment?
Has support/advicebeen given concerningTelecare or equipment?
Yes No

Finance
Are you finding it difficult to manage on your own income?
Yes No
Are you experiencing additional costs through caring?
Yes No
Have you received any advice about to benefits for yourself, or the person you care for?
Yes No
Would you like information about financial advice or benefits?
Yes No
Has support/information/advicebeen given concerningFinance?
Yes No

Support and Advice
What would help in your caring role?
If you are not already in contact with the Richmond Carers Centre, would you like to be referred to them?For confidential support and advice ring the Carers Centre 020 8744 3900
Yes No Already in contact
Date Referred:
Is there any other organisation(s) you would like to be referred to (For Example Richmond Crossroads Caring Café, RBMind, MENCAP)?
Yes No
If ‘Yes’ Details
Date Referred:
ConfidentialITY and Information Sharing
The information you have given is confidential. It will only be shared with your permission.
Please tick here if you are happy for information on this form to be shared with other people who need to know
Signature:
Date:
Please tick here if your are happy for the information on this form to be shared with the person for whom you are caring, if they need to know
Signature:
Date:
Statement of Need and CARERS ACTIONPlan
Family Name:
First Name:
Ref:
Summary of carers needs:
Overall level of risk identified:
Low / Moderate / Substantial / Critical
CARERS RAS OUTCOME

Is the carer eligible for a Carers Payment?
Yes No
How Much
£

CARERS ACTION PLAN
Action / Who Responsible / Timescale
Professional completing this form -
Name:
Signature:
Date:
Carer completing this form -
Name:
Signature:
Date: