What If? Plan Registration Form

Referrer Name / Referrer Organisation

This plan is to help you think about, be prepared and have peace of mind in the case of an unplanned event or emergency wherein you are unable to look after the person you care for.

·  What counts as an Emergency?

An Emergency counts as anything that you have not been able to plan for such as:

-  Sudden illness

-  Unplanned admission to hospital

-  Family emergency (e.g. close relative taken ill)

-  Risk to your employment

·  Please refer to the What If? Plan Guidance Notes for complete details on how to fill out this form.

·  Please feel free to contact Carers Trust Cambridgeshire on 01480 499090 for further assistance in filling out this form.

·  If you would like to receive a copy of this form by email, in large print, audio, Braille or any other language please contact Carers Trust Cambridgeshire on 01480 499090.

·  If you care for more than one person you should complete a separate What If? Plan for each person that you care for.

·  To help us record essential information accurately, it is essential that:

ALL sections marked with an asterisk (*) are to be completed legibly and in BLOCK LETTERS (these are mandatory fields)

Information we need about you, the main carer:

Title
First Name*
Preferred name if different
Last Name*
Address 1*
Address 2
Town
County
Postcode*
Email Address
Telephone: Home
Telephone: Other daytime contact*
Telephone: Mobile
Date of Birth* / D / D / M / M / Y / Y / Y / Y
GP Surgery Name*
I am happy for you to let my GP know that I am a carer.*
(This will help your GP surgery to support you).
☐ Yes ☐ No

The following questions are optional but the information you supply will help us better understand the needs of all family carers so that we can tailor our support to you. We will also use this information to monitor the services we provide. Responses to these questions remain confidential. Individuals will not be identified and personal details will not be published.

How long can you leave the person you care for?
☐ Never ☐ 1 – 2 Hours ☐ Up to 4 Hours ☐ Up to 8 Hours ☐ Overnight
Are you registered disabled? ☐ Yes ☐ No
Do you have any kind of a health condition requiring ongoing medical attention? ☐ Yes ☐ No
Please state your ethnic origin.
(This would help us determine whether or not we are meeting the needs of all carers)
☐ Asian or Asian British - Bangladeshi
☐ Asian or Asian British – Indian
☐ Asian or Asian British – Pakistani
☐ Any other Asian background
☐ Black or Black British - African
☐ Black or Black British – Caribbean / ☐ Any other Black background
☐ Chinese
☐ Mixed - White & Asian
☐ Mixed - White & Black African
☐ Mixed - White & Black Caribbean
☐ Any other mixed background / ☐ Traveller
☐ White - British
☐ White - Irish
☐ White – Other
☐ Any other ethnic group
☐ Do not wish to disclose
Please tell us where you heard about the What If? Plan and Carers Emergency Card?

Information we need about the person you care for:

Please complete the following after checking that the person you care for consents for this information to be shared with us:

Title
First name*
Preferred name if different
Last Name*
Address 1*(if different to yours)
Address 2
Town
County
Postcode*
If you think this is an address that is difficult to locate for a first-time visitor, please could you give us directions/landmarks that would help us locate the property?
Email Address
Contact Number to be used in case of an emergency*
Telephone: Home
Telephone: Mobile
Date of Birth* / D / D / M / M / Y / Y / Y / Y
GP Surgery Name* (if known)
Main language spoken/understood
Does the person require an interpreter? / ☐ Yes ☐ No
Relationship to you: the person I care for is my…
Does this person receive support from a Health or Adult Social Care Team?
If ‘yes’, please could you provide their contact details. / ☐ Yes ☐ No

Information we need about the person you care for:

Please complete the following after checking that the person you care for consents for this information to be shared with us:

Why do you look after them - what is their illness or condition?*
(Please put a tick mark against all applicable conditions)
☐ Abdominal Conditions
☐ ADD / ADHD
☐ Allergies
☐ Alzheimer’s / Dementia
☐ Arthritis
☐ Autistic Spectrum
☐ Blood Disorders
☐ Bronchitis / Asthma / Respiratory
☐ Cancer
☐ Cerebral Palsy
☐ Crohn's Disease
☐ Cystic Fibrosis
☐ Diabetes
☐ Down's Syndrome
☐ Dyspraxia / ☐ Ehlers-Danlos Syndrome (EDS)
☐ Elderly Frail
☐ Elderly Mentally Ill (Emi)
☐ Epilepsy
☐ Fatigue Disorders
☐ Fragile X Syndrome
☐ Head / Brain Injury
☐ Heart Disease / Disorders
☐ HIV / AIDS
☐ Huntington's Disease
☐ Learning Difficulties / Disability
☐ Memory Problems
☐ Mental Health Problems (Not Alzheimer’s / Dementia)
☐ Mobility Problems / ☐ Motor Neurone Disease
☐ Multiple Sclerosis
☐ Muscular Dystrophy
☐ Osteoporosis
☐ Parkinson's Disease / Syndrome
☐ Renal Disease
☐ Sensory Impairment - Hearing
☐ Sensory Impairment - Other
☐ Sensory Impairment - Sight
☐ Spinabifida
☐ Spinal Injury
☐ Stroke
☐ Substance Misuse (Drug And Alcohol)
☐ Undiagnosed
☐ None
Others
(Please specify. Please use this section to tell us about:
·  any specialist equipment that they use e.g. walking frame, hoist, turn safe, alarms, assistive technology, falls mats, etc.
·  any help that they require that requires specialist training e.g. peg feed, if they are on prescribed insulin or oxygen.
·  any memory problems or challenging behaviours that we need to be aware of.)

What If something happens to you, which means you are unable to look after this person? Who could help? Who would you want to be contacted on your behalf?

(e.g. family, friend, paid carer - someone who can take over some of your caring duties.)

If you do not have any family or friends that can be nominated as emergency contacts for the purposes of this plan, you can still register with the scheme and our emergency call-out team can step in to help for up to the first 24 hours from activation.

Main Nominated Contact 1 / Nominated Contact 2 / Care Agency Involved
Title
First name*
Last Name*
Address 1*
Address 2
Town
County
Postcode*
Email Address
Contact Number to be used in case of an emergency*
Telephone: Home
Telephone: Work
Telephone: Mobile
How is the nominated person related to you?
Does this person have a key or know the code to the key safe?*
(Tick the appropriate option) / ☐ Has a key
☐ Has access to the key safe
☐ Neither of the above / ☐ Has a key
☐ Has access to the key safe
☐ Neither of the above / ☐ Has a key
☐ Has access to the key safe
☐ Neither of the above
For security reasons, please do not record key safe numbers/alarm codes/details of any other security arrangements anywhere on this form.
Before returning your form, please phone Carers Trust Cambridgeshire on 01480 499090, who will record the information separately.

If you would like to nominate more than two contacts for the purposes of this plan, please attach additional sheets to this form and provide the above details for the additional nominees.

Information about your key-holder

If none of your nominated contacts are available, who else lives locally and holds a key to the home of the person you look after? The key-holder is not expected to provide any practical support; they would be called upon to manage access to the property if needed.

Additional Key-holder 1 / Additional Key-holder 2
Title
First name*
Last Name*
Address 1*
Address 2
Town
County
Postcode*
Email Address
Contact Number to be used in case of an emergency*
Telephone: Home
Telephone: Work
Telephone: Mobile

Additional information that might be needed:

Are there any young people who help to care for this person who may benefit from our support? / ☐ Yes ☐ No
Do any children under the age of 13 live with the person you care for? / ☐ Yes ☐ No
There must be a responsible person who will care for any children in the home under the age of 13 in an emergency situation. Please state which of your nominated contacts will be responsible, or if someone else will be responsible for the children please give their name and phone number here.

What happens next?

·  Please sign and return these forms to:

Carers Trust Cambridgeshire, 4 Meadow Park, Meadow Lane, St Ives, Cambridgeshire, PE27 4LG

or via email to:

·  Before returning the form, if you have key safe numbers/alarm codes/details of any other security arrangements that you would like to make us aware of, please phone Carers Trust Cambridgeshire on 01480 499090, who will record the information separately. Please do not record these details anywhere on this form.

·  On receipt of your What If? Plan, we will register you and send you:

-  an Emergency Card with your unique card number and contact details to use in an emergency

-  a copy of your plan for your records

-  copies of your plan to share with your nominated contacts.

·  You must let us know if any information given to us changes. You can do this by either:

-  calling the number 01480 499090 or

-  emailing changes to

·  You must let us know if your key safe numbers/alarm codes/details of any other security arrangements that you have given us change by calling us on 01480 499090.

What If? Plan Registration Form V13 April 2016 8 of 8

What to do in an Emergency?

In the case of an emergency, call our Emergency Number 0300 666 0213. We will first call your nominated contacts; usually this would be better for the person you care for than bringing in someone who is unfamiliar. If they are unable to help, or there is nobody you feel you can ask, our emergency call-out team can step in to help during the first 24 hours. This is a free service funded by Cambridgeshire County Council available 24 hours a day, 7 days a week.

After that initial period, if help is still needed and friends and family are not available, Carers Trust Cambridgeshire can provide professional care or you are entitled to choose another provider (e.g. a home care agency) to provide this service, if you wish. You would have to pay for this support. We will also try to link you up with a volunteer to help with one off and short term tasks.

We may need to refer you to Cambridgeshire County Council’s Adult Social Care Service to ensure that care is provided for the person you look after whilst you are unavailable. If the person you look after is eligible for adult social care support, the County Council will carry out a financial assessment, after which they will be able to tell you how much the Council can contribute to the cost of your care and how much your contribution will be. Full details of their fairer contributions policy can be found on their web site. http://www.cambridgeshire.gov.uk/info/20161/care_and_support/572/paying_for_care/3

If you think you might want to purchase care and support from Carers Trust Cambridgeshire when you have an emergency please confirm that you are familiar with our Fees and have read our Terms & Conditions of providing care which you will find in our Guidance Notes). ☐ (tick if yes)

Would you be interested in details about setting aside a sum to provide care in the case of an emergency? ☐ (tick if yes)

Is there an upper limit you would like to set aside for this? (specify amount)

If someone from a specific organisation helped you to complete this plan, please add their details here so we can acknowledge their support

Their
Organisation / Date they helped you complete the plan
Their
Name / Their Signature

Confirmation of Registration

1.  Please register my What If? Plan for the emergency service and send me an Emergency Card.

2.  I confirm that I have discussed the What If? Plan with my nominated emergency contacts and that they are aware that Carers Trust Cambridgeshire will hold their details for this purpose. I take responsibility of providing my nominated emergency contacts with a copy of my What if? Plan.

3.  I confirm that the person I look after is aware that I have made this plan, agrees to register with the scheme and is aware that Carers Trust Cambridgeshire will hold their details for this purpose and that in the case of an emergency these details might need to be shared with relevant professionals for the purpose of arranging support.

4.  I will notify you of changes to the plan as they arise.