If you would like more information on the support services available to you,

please telephone our Carers Helpline or visit our website on

Carers Helpline: 01702 393933

Registered Charity No. 1093240

Details about you the Carer

Title: / Mr Mrs Ms  Miss  Other (please indicate) ………………………………
Name:
D.O.B.: / Gender: /  M  F  Transgender Prefer not to say
Address:
Telephone: / Mobile: / Email:
What is your ethnic origin?
Please choose one option () that best describes your ethnic group or background
White / Mixed / Multiple ethnic groups / Asian / Asian British
English / Welsh / Scottish / Northern Irish/British
Irish
Gypsy or Irish Traveller
Any other White background / White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic background / Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black / African / Caribbean / Black British / Other ethnic group
African
Caribbean
Any other Black / African / Caribbean background / Arab
Any other ethnic group
 Prefer not to say

Details about your caring role

Are you the main or secondary carer? Primary Secondary 
How long have you been caring?
Up to 12 months /  / Between 1 to 3 Yrs /  / Between 4 to 6 Yrs / 
Between 7 to 10 Yrs /  / Between 11 to 15 Yrs /  / Between 16 to 19 Yrs / 
Over 20 yrs + /  /  / 
How many hours care per week do you provide care to this person?
0 - 5 hours /  / 5 - 10 hours /  / 11 - 20 hours /  / 21 - 30 hours / 
31 - 40 hours /  / 41 - 50 hours /  / 50+ hours / 
In what areas do you care, assist or help this person?
Personal care (dressing, washing) /  / Practical help (cleaning, ironing) / 
Meals (feeding, meal preparation) /  / Emotional care/support / 
Administering Medication /  / Helping to manage their Finances / 
Support to stay safe (emergency) /  / Socialising (taking out) / 

Have you had a Carers Assessmentconducted by the local authority? No  Yes 

Are you in receipt of a Carers Personal Budget? No  Yes 

If you do receive a Personal Budget from the Local Authority, is it paid to you via Carers Direct Payment? No  Yes 

What Carer’s services have you either accessed or are in receipt of at the moment?

Carers Advocacy /  / Carers Counselling /  / Benefits Advice / 
Emergency Planning /  / Peer/social support groups /  / Financial Advice / 
Wills Advice /  / Lasting Power of Attorney /  / Training courses / 
Home adaptations /  / Employment support /  / Education support / 

How would you describe your physical wellbeing and health?

Very Good / Good / Quite Good / Not that Good / Bad / Very Bad
Physical health /  /  /  /  /  / 
Emotion /  /  /  /  /  / 
Moods /  /  /  /  /  / 
Anxiety /  /  /  /  /  / 
Sleeping pattern /  /  /  /  /  / 

Is your GP aware that you are a Carer? No  Yes 

Your doctors Name:
GP Practice Address:
Postcode: / Telephone No:
Are you juggling education, training or work and caring? Yes No 
I am in full time education /  / I am in part-time education /  / I am undertaking training / 
I am in full time work /  / I am in part-time work /  / I do not work / 
How would prefer to receive information from Southend Carers?
via post /  / via email /  / via text /  / via website /  / via Facebook / 
Where did you hear about Southend Carers?

Details about the person you care for

Title: / Mr Mrs Ms  Miss  Other (please indicate) ………………………………
Name:
D.O.B.: / Gender: /  M  F  Transgender Prefer not to say
Address:
Telephone: / Mobile: / Email:
What is your ethnic origin?
Please choose one option () that best describes your ethnic group or background
White / Mixed / Multiple ethnic groups / Asian / Asian British
English / Welsh / Scottish / Northern Irish/British
Irish
Gypsy or Irish Traveller
Any other White background / White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic background / Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black / African / Caribbean / Black British / Other ethnic group
African
Caribbean
Any other Black / African / Caribbean background / Arab
Any other ethnic group
 Prefer not to say
Relationship: He/she is my:
The nature of their ailment/disability is:
CONSENT TO SHARE THIS INFORMATION
In accordance with the Data Protection Act 1998, thepersonal information collected on this form will be stored safely, and be used for the purposes of providing you with information and advice about the support services available to Carers in Southend-on-Sea borough and nationally.
This information, with your consent, will be used to enable Southend Carers and our partners to provide you with appropriate assistance, services and support, and aid us to monitor and administrate the services delivered.
I confirm that I have read the Data Protection statement above and agree to its terms & conditions
I understand that the information I have provided, will be processed by computer and managed effectively and confidentially in accordance with the Data Protection Act 1998
I understand that the information I provide on this Form will only be shared as allowed by the Data Protection Act 1998
Signed: ______Date: ______

Please return the completed registration form to:

Southend Carers, ANG11464, Southend-on-Sea, Essex, SS1 1ZX

Carers Registration Form 2015 - Young Adult Carers.docx

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