CARER'S ASSESSMENT


Personal Information and Contact Details

We need to collect some basic personal details from you such as your date of birth and address. These will only be used to provide you with support that is identified as part of this carers assessment.

We will only share information with relevant organizations that can help you, on a need-to-know basis and we will ask you before we do so. Information is shared in a GDPR compliant manner.
How do you like to be addressed.
This is your last or family name.
This could be the name you are used to or whether you would prefer us to be more formal.
Don't worry, we will not be sharing your age with anyone, we just need it for our records and to make sure that we are providing you with appropriate information.
Address Line 1
Address Line 2
City
Country
Post Code
Your email address, that will be used to send you a copy of this assessment and your Support Plan
What gender do you identify as? At Barnet Carers, we make sure all carers are treated with respect and dignity and valued in their singularities.
As part of our committment to equality, we want to make sure that people from all Barnet communities are being offered support as carers.
We ask this because your culture and religious beliefs can help us identify what support is available for you, respecting your ideas and preferences.
Please try and identify your GP from the list. If you cannot find your GP surgery please select "Other".

Language and Communication

We want to find out a bit more about the best way of communicating with you. The more we know the easier it is.

We will try and get someone to speak to you who can speak your language. This is not always possible and if necessary we will organise for an interpreter.
Do you need someone to help you to communicate in English?
Please tell us if there is someone helping you complete this form or what other arrangement was made.
For example, are you hard of hearing? Do you use sign language?
What is the easiest way to get in touch with you?

The Person you Care For

Now we are going to ask you some questions about the person you care for. This is so that we can get a good idea of the care you are offering and can make sure that your carers action plan fits you as well as it can.

Address Line 1
Address Line 2
City
Post Code
What gender do they identify as?
As part of our committment to equality, we want to make sure that people from all Barnet communities are being offered support as carers.
Please try and identify your GP from the list. If you cannot find your GP surgery please select "Other".

About your Caring Role

Tick as many as apply.

We need to know if you have any concerns about your personal safety when carrying out your caring responsibilities. Remember, this assessment is confidential. However, if you tell us that you do not feel safe, we can help you by sending a Safeguarding alert to your local authority.

Feel free to say as much or as little as you want. But remember, we are only concerned about your wellbeing. If something is not right, we can help you with that.
What kind of tasks do you help your loved one with? It does not have to be something you do every day.
Please tell us if you have caring responsibilities for someone else other than the previously identified cared for person.
Are you still able to provide care for any other persons you care for?
What support could be put in place to help you manage your multiple caring roles?

Your Wellbeing

Please tell us about how your caring role affects your general health and wellbeing. For example, you may want to tell us if you have any concerns about your health, if you have any diagnosis / registered disability, if your caring role interferes with your sleep, affects your mood or how you feel, or causes you any physical pain or strain.

Have you got any disabilities or any health conditions?
We need to know this to make sure any support we offer will respect your health condition and possible limitations.

Your Family and Personal Relationships

Your Family and Personal Relationships

Tick "yes" if you don't get to spend much time with your friends and family because you are performing your caring duties.
You can select more than one option.
You can tick more than one option.
Please tell us any other comments you would like to make about this area.

Home Environment

Please tell us if your caring role is preventing you from maintaining your household tasks.

Tick "yes" if you have been prevented from performing your house chores (e.g. cleaning, cooking, shopping), because of your caring role.
You can tick more than one option.
You can tick more than one option.

Paid Work, Training and Volunteering

Tick as many as applies.
We can help you by referring you to the relevant organizations in the Borough!
Please write here any other comments about this are that you would like to make.

Recreational and Community Activities

What support do you have in place that helps you enjoying time away from your caring role?
Please tell us more about what you enjoy doing in your spare time, for example reading, gardening, swimming, etc.

Emergency Plans

If you do not have any plans in place, you can complete a Carers Emergency Plan.