Carer Registration Form to be completed by people who identify themselves as an unpaid carer. Register as a Carer "*" indicates required fields Step 1 of 3 - Carer Details 33% Name* DrMissMrMrsMsProf.Rev. Title First Last How would you like us to address you?Date of Birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City Postcode Please Note A home telephone number or a mobile number is required so that we can communicate with you.Home Phone No.Mobile No.*Email Gender*-Please select from options-MaleFemaleNon-binaryPrefer Not To SayOtherOther, please state [Gender]*Religion*-Please select from options-JewishChristianMuslimSikhBuddhistAgnosticHinduAtheistOtherDo Not Wish To DiscloseOther, please state [Religion]Ethnicity*-Please select from options-Asian Or Asian British - Any Other AsianAsian Or Asian British - BangladeshiAsian Or Asian British - ChineseAsian Or Asian British - IndianAsian Or Asian British - PakistaniBlack Or Black British - AfricanBlack Or Black British - CaribbeanBlack Or Black British - Other Black BackgroundMixed - Other Mixed BackgroundMixed - White And AsianMixed - White And Black AfricanMixed - White And Black CaribbeanWhite - Any Other White BackgroundWhite - BritishWhite - IrishWhite - JewishAny Other Other Ethnic GroupPrefer Not To SayOther, please state [Ethnicity]Your GP*-Please select from options-Addington Medical CentreAlexander Park SurgeryBacon Lane SurgeryBrunswick Park Health CentreCockfoster Medical CentreColindale Medical CentreColindeep Lane SurgeryColney Hatch SurgeryCornwall House SurgeryCricklewood Health CentreDeans Lane SurgeryDerwent Medical CentreDr Azim & PartnersEast Barnet Health CentreEast Finchley Medical PracticeEverglade Medical PracticeFinchley Practice (The)Friern Barnet Medical CentreGloucester Road SurgeryGrahame Park Health CentreGreenfield Medical CentreHampden Square Medical CentreHeathfielde Medical CentreHendon Way SurgeryHillview SurgeryHodford Road Surgery TheJai Medical CentreLane End Medical GroupLangstone Way SurgeryLichfield Grove SurgeryLongrove SurgeryMillway Medical PracticeMountfield SurgeryMulberry Medical Practice (Main)Oak Lodge Medical CentreOakleigh Road Health Centre (The Clinic)Old Courthouse SurgeryOut of BoroughParkview SurgeryPennine Drive SurgeryPenshurst Gardens SurgeryPHGH DoctorsPhoenix Surgery, Clare HouseRavenscroft Medical CentreRiley house SurgeryRosemary SurgeryRutland House SurgerySouthgate SurgerySpeedwell Practice (The)Squires Lane Medical PracticeSt Andrews Medical PracticeSt George’s Medical CentreSt Johns Villas SurgerySupreme Medical CentreTeam Hc Brunswick Park Hth CtrTemple Fortune Medical GroupThe Practice @ 188The Village SurgeryTorrington Park Group PracticeVale Drive Medical PracticeWakemans Hill SurgeryWatling Medical Centre (London Road)Watling Medical Centre (Watling Avenue)Wentworth Medical PracticeWillow Court SurgeryWoodcroft Medical CentreWoodlands Medical PracticeOtherIf your GP surgery is not listed, please select OtherGP Surgery AddressIf you do not know your GP's address, please leave blankDo you have a health or medical condition that impacts your caring role?* Yes No If Yes, what condition are you affected by*-Please select from options-Autistic Spectrum Disorder (ASD)Learning DisabilityCancerDementiaMental Health IssuePhysical DisabilityDrug/Alcohol DependencyFrail Through AgingOtherWhat is your preferred language?*Do you require an interpreter? Yes No What is your employment status?*-Please select from options-Full-time employedPart-time employedSelf-employedUnemployedRetiredFull-time carerStudentVolunteeringOtherIf Other, please give details Who do you care for?*-Please select from options-Person(s) over the age of 18Person(s) under the age of 18BothHow many people under the age of 18 do you care for?*-Please select from options-OneTwoThreeFourHow many people over the age of 18 do you care for?*-Please select from options-OneTwoThreeHow many hours of care do you provide per week?*-Please select from options-0-78-2122-3435 or moreName of Person Being Cared For* DrMissMrMrsMsProf.Rev. Title First Last Relationship to Person Being Cared For*-Please select from options-BrotherDaughterFatherFriendGrandchildGrandparentHusbandMotherNeighbourParentPartnerSisterSonStep ChildStep ParentWifeOther relativeNot statedOther, please state [Person Being Cared For's Relationship]*Person Being Cared For's Date of Birth* DD slash MM slash YYYY Do you live with the Person Being Cared For?* Yes No Address of Person Being Cared For* Street Address Address Line 2 City Postcode How long have you been caring for the Person Being Cared For?-Please select from options-Less than 1 year1-3 years4-6 years7-8 years9-10 years10 years +Since they were bornAre you the Person Being Cared For's Primary or Secondary Carer?-Please select from options-PrimarySecondaryPerson Being Cared For's Gender*-Please select from options-MaleFemaleNon-binaryPrefer Not To SayOtherOther, please state [Person Being Cared For's Gender]Person Being Cared For's Religion-Please select from options-JewishChristianMuslimSikhBuddhistAgnosticHinduAtheistOtherDo Not Wish To DiscloseOther, please state [Person Being Cared For's Religion]Person Being Cared For's Ethnicity*-Please select from options-Asian Or Asian British - Any Other AsianAsian Or Asian British - BangladeshiAsian Or Asian British - ChineseAsian Or Asian British - IndianAsian Or Asian British - PakistaniBlack Or Black British - AfricanBlack Or Black British - CaribbeanBlack Or Black British - Other Black BackgroundMixed - Other Mixed BackgroundMixed - White And AsianMixed - White And Black AfricanMixed - White And Black CaribbeanWhite - Any Other White BackgroundWhite - BritishWhite - IrishWhite - JewishAny Other Other Ethnic GroupPrefer Not To SayOther, please state [Person Being Cared For's Ethnicity]GP of Person Being Cared For*-Please select from options-Addington Medical CentreAlexander Park SurgeryBacon Lane SurgeryBrunswick Park Health CentreCockfoster Medical CentreColindale Medical CentreColindeep Lane SurgeryColney Hatch SurgeryCornwall House SurgeryCricklewood Health CentreDeans Lane SurgeryDerwent Medical CentreDr Azim & PartnersEast Barnet Health CentreEast Finchley Medical PracticeEverglade Medical PracticeFinchley Practice (The)Friern Barnet Medical CentreGloucester Road SurgeryGrahame Park Health CentreGreenfield Medical CentreHampden Square Medical CentreHeathfielde Medical CentreHendon Way SurgeryHillview SurgeryHodford Road Surgery TheJai Medical CentreLane End Medical GroupLangstone Way SurgeryLichfield Grove SurgeryLongrove SurgeryMillway Medical PracticeMountfield SurgeryMulberry Medical Practice (Main)Oak Lodge Medical CentreOakleigh Road Health Centre (The Clinic)Old Courthouse SurgeryOut of BoroughParkview SurgeryPennine Drive SurgeryPenshurst Gardens SurgeryPHGH DoctorsPhoenix Surgery, Clare HouseRavenscroft Medical CentreRiley house SurgeryRosemary SurgeryRutland House SurgerySouthgate SurgerySpeedwell Practice (The)Squires Lane Medical PracticeSt Andrews Medical PracticeSt George’s Medical CentreSt Johns Villas SurgerySupreme Medical CentreTeam Hc Brunswick Park Hth CtrTemple Fortune Medical GroupThe Practice @ 188The Village SurgeryTorrington Park Group PracticeVale Drive Medical PracticeWakemans Hill SurgeryWatling Medical Centre (London Road)Watling Medical Centre (Watling Avenue)Wentworth Medical PracticeWillow Court SurgeryWoodcroft Medical CentreWoodlands Medical PracticeOtherIf their GP surgery is not listed, please select OtherPerson Being Cared For's GP AddressIf you do not know the GP's address, please leave blankWhat condition is the person you care for affected by?* Autistic Spectrum Disorder (ASD) Learning Disability Cancer Dementia Mental Health Issue Physical Disability Drug/Alcohol Dependency Frail Through Aging Other Other, please state [Person Being Cared For's Condition]*Please give details as to the Person Being Cared For's conditionName of Person Being Cared For #2* DrMissMrMrsMsProf.Rev. Title First Last Relationship to Person Being Cared For #2*-Please select from options-BrotherDaughterFatherFriendGrandchildGrandparentHusbandMotherNeighbourParentPartnerSisterSonStep ChildStep ParentWifeOther relativeNot statedOther, please state [Person Being Cared For #2's Relationship]*Person Being Cared For #2's Date of Birth* DD slash MM slash YYYY Do you live with the Person Being Cared For #2?* Yes No Address of Person Being Cared For #2* Street Address Address Line 2 City Postcode How long have you been caring for the Person Being Cared For #2?*-Please select from options-Less than 1 year1-3 years4-6 years7-8 years9-10 years10 years +Since they were bornAre you the Person Being Cared For #2's Primary or Secondary Carer?-Please select from options-PrimarySecondaryPerson Being Cared For #2's Gender*-Please select from options-MaleFemaleNon-binaryPrefer Not To SayOtherOther, please state [Person Being Cared For #2's Gender]*Person Being Cared For #2's Religion-Please select from options-JewishChristianMuslimSikhBuddhistAgnosticHinduAtheistOtherDo Not Wish To DiscloseOther, please state [Person Being Cared For #2's Religion]Person Being Cared For #2's Ethnicity*-Please select from options-Asian Or Asian British - Any Other AsianAsian Or Asian British - BangladeshiAsian Or Asian British - ChineseAsian Or Asian British - IndianAsian Or Asian British - PakistaniBlack Or Black British - AfricanBlack Or Black British - CaribbeanBlack Or Black British - Other Black BackgroundMixed - Other Mixed BackgroundMixed - White And AsianMixed - White And Black AfricanMixed - White And Black CaribbeanWhite - Any Other White BackgroundWhite - BritishWhite - IrishWhite - JewishAny Other Other Ethnic GroupPrefer Not To SayOther, please state [Person Being Cared For #2's Ethnicity]GP of Person Being Cared For #2*-Please select from options-Addington Medical CentreAlexander Park SurgeryBacon Lane SurgeryBrunswick Park Health CentreCockfoster Medical CentreColindale Medical CentreColindeep Lane SurgeryColney Hatch SurgeryCornwall House SurgeryCricklewood Health CentreDeans Lane SurgeryDerwent Medical CentreDr Azim & PartnersEast Barnet Health CentreEast Finchley Medical PracticeEverglade Medical PracticeFinchley Practice (The)Friern Barnet Medical CentreGloucester Road SurgeryGrahame Park Health CentreGreenfield Medical CentreHampden Square Medical CentreHeathfielde Medical CentreHendon Way SurgeryHillview SurgeryHodford Road Surgery TheJai Medical CentreLane End Medical GroupLangstone Way SurgeryLichfield Grove SurgeryLongrove SurgeryMillway Medical PracticeMountfield SurgeryMulberry Medical Practice (Main)Oak Lodge Medical CentreOakleigh Road Health Centre (The Clinic)Old Courthouse SurgeryOut of BoroughParkview SurgeryPennine Drive SurgeryPenshurst Gardens SurgeryPHGH DoctorsPhoenix Surgery, Clare HouseRavenscroft Medical CentreRiley house SurgeryRosemary SurgeryRutland House SurgerySouthgate SurgerySpeedwell Practice (The)Squires Lane Medical PracticeSt Andrews Medical PracticeSt George’s Medical CentreSt Johns Villas SurgerySupreme Medical CentreTeam Hc Brunswick Park Hth CtrTemple Fortune Medical GroupThe Practice @ 188The Village SurgeryTorrington Park Group PracticeVale Drive Medical PracticeWakemans Hill SurgeryWatling Medical Centre (London Road)Watling Medical Centre (Watling Avenue)Wentworth Medical PracticeWillow Court SurgeryWoodcroft Medical CentreWoodlands Medical PracticeOtherIf their GP surgery is not listed, please select OtherPerson Being Cared For #2's GP AddressIf you do not know the GP's address, please leave blankWhat condition is the person you care for #2 affected by?* Autistic Spectrum Disorder (ASD) Learning Disability Cancer Dementia Mental Health Issue Physical Disability Drug/Alcohol Dependency Frail Through Aging Other Other, please state [Person Being Cared For #2's Condition]*Please give details as to the Person Being Cared For #2's conditionName of Person Being Cared For #3* DrMissMrMrsMsProf.Rev. Title First Last Relationship to Person Being Cared For #3*-Please select from options-BrotherDaughterFatherFriendGrandchildGrandparentHusbandMotherNeighbourParentPartnerSisterSonStep ChildStep ParentWifeOther relativeNot statedOther, please state [Person Being Cared For #3's Relationship]*Person Being Cared For #3's Date of Birth* DD slash MM slash YYYY Do you live with the Person Being Cared For #3?* Yes No Address of Person Being Cared For #3* Street Address Address Line 2 City Postcode How long have you been caring for the Person Being Cared For #3?-Please select from options-Less than 1 year1-3 years4-6 years7-8 years9-10 years10 years +Since they were bornAre you the Person Being Cared For #3's Primary or Secondary Carer?-Please select from options-PrimarySecondaryPerson Being Cared For #3's Gender*-Please select from options-MaleFemaleNon-binaryPrefer Not To SayOtherOther, please state [Person Being Cared For #3's Gender]*Person Being Cared For #3's Religion-Please select from options-JewishChristianMuslimSikhBuddhistAgnosticHinduAtheistOtherDo Not Wish To DiscloseOther, please state [Person Being Cared For #3's Religion]Person Being Cared For #3's Ethnicity*-Please select from options-Asian Or Asian British - Any Other AsianAsian Or Asian British - BangladeshiAsian Or Asian British - ChineseAsian Or Asian British - IndianAsian Or Asian British - PakistaniBlack Or Black British - AfricanBlack Or Black British - CaribbeanBlack Or Black British - Other Black BackgroundMixed - Other Mixed BackgroundMixed - White And AsianMixed - White And Black AfricanMixed - White And Black CaribbeanWhite - Any Other White BackgroundWhite - BritishWhite - IrishWhite - JewishAny Other Other Ethnic GroupPrefer Not To SayOther, please state [Person Being Cared For #3's Ethnicity]GP of Person Being Cared For #3*-Please select from options-Addington Medical CentreAlexander Park SurgeryBacon Lane SurgeryBrunswick Park Health CentreCockfoster Medical CentreColindale Medical CentreColindeep Lane SurgeryColney Hatch SurgeryCornwall House SurgeryCricklewood Health CentreDeans Lane SurgeryDerwent Medical CentreDr Azim & PartnersEast Barnet Health CentreEast Finchley Medical PracticeEverglade Medical PracticeFinchley Practice (The)Friern Barnet Medical CentreGloucester Road SurgeryGrahame Park Health CentreGreenfield Medical CentreHampden Square Medical CentreHeathfielde Medical CentreHendon Way SurgeryHillview SurgeryHodford Road Surgery TheJai Medical CentreLane End Medical GroupLangstone Way SurgeryLichfield Grove SurgeryLongrove SurgeryMillway Medical PracticeMountfield SurgeryMulberry Medical Practice (Main)Oak Lodge Medical CentreOakleigh Road Health Centre (The Clinic)Old Courthouse SurgeryOut of BoroughParkview SurgeryPennine Drive SurgeryPenshurst Gardens SurgeryPHGH DoctorsPhoenix Surgery, Clare HouseRavenscroft Medical CentreRiley house SurgeryRosemary SurgeryRutland House SurgerySouthgate SurgerySpeedwell Practice (The)Squires Lane Medical PracticeSt Andrews Medical PracticeSt George’s Medical CentreSt Johns Villas SurgerySupreme Medical CentreTeam Hc Brunswick Park Hth CtrTemple Fortune Medical GroupThe Practice @ 188The Village SurgeryTorrington Park Group PracticeVale Drive Medical PracticeWakemans Hill SurgeryWatling Medical Centre (London Road)Watling Medical Centre (Watling Avenue)Wentworth Medical PracticeWillow Court SurgeryWoodcroft Medical CentreWoodlands Medical PracticeOtherIf their GP surgery is not listed, please select OtherPerson Being Cared For #3's GP AddressIf you do not know the GP's address, please leave blankWhat condition is the person you care for #3 affected by?* Autistic Spectrum Disorder (ASD) Learning Disability Cancer Dementia Mental Health Issue Physical Disability Drug/Alcohol Dependency Frail Through Aging Other Other, please state [Person Being Cared For #3's Condition]*Please give details as to the Person Being Cared For #3's conditionPlease select services that you would be interested in accessing via Barnet Carers (select as many that apply)* Carers Needs Assessment and Support Plan General information and advice Legal Advice Form-checking (for benefits forms) Training Employability Support Carers Essentials Grant Emergency Card Scheme Counselling Health and Wellbeing Services (i.e. exercise classes, peer-support groups, social events) Barnet Leisure Pass Are there agencies currently supporting you or the person(s) being cared for?* Yes No Name of Agency #1*Name of Contact: Agency #1* First Last Job Title of Contact: Agency #1Contact No. of Agency #1Email of Contact: Agency #1 Involvement of Agency #1*Name of Agency #2*Name of Contact: Agency #2* First Last Job Title of Contact: Agency #2*Contact No. of Agency #2Email of Contact: Agency #2 Involvement of Agency #2*How did you hear about Barnet Carers?*-Please select from options-GPSocial ServicesFamily and friendsPosters or leafletsBarnet Carers websiteBarnet Carers social mediaOtherOther, please state [How did you hear about us?]*Barnet Carers Consent - We will save your personal data in our database following due GDPR procedures.* I give consent for my details to be held by Barnet CarersOnline Carers Assessment In order to understand the carer's caring responsibilities, impact of their caring role and personal interests, we request that the carer completes the following form so we can tailor services to their needs Please click on this link if you wish to complete an online self-assessment, accessible 24 hours a day. Alternatively, should you wish to book a telephone assessment. Please click on this link if you wish to book a telephone assessment with one of our team.Sign Up For Information Sign up to our email and get information straight into your inbox. We send a regular newsletter out on a Sunday evening which lets you know about all of the things that we have going on. We don’t try and sell you things and we don’t try to fundraise. Our newsletter is all about services and information to help you in your caring role. Why not give it a try. If you don’t like it you can always unsubscribe with one click. But we are convinced that you will like it. Please click on this link, if you wish to sign up and join the 2,500 other carers in Barnet and beyond who receive our regular newsletter.
