Carers Details

 
 
 
 
 
 
 

State Ethnic Origin

 

*Brief description of caring role and reason for refferal

 

Persons "Cared For"

Person 1
 
 
 
Person 2
 
 
Referrer
 
 
 

Please select below on a scale of 1-4 how much you feel your Health, Social life and Work are affected by your caring role.
1 = Not at all 2 = Some of the time 3 = Most of the time 4 = All of the time

*How much do you feel your own health is being affected by your caring role?

 

*How much do you feel your social life is being affected by your caring role?

 

*How much do you feel your work/education is affected by your caring role?

 

*How much do you feel your role as a carer affects your relationships e.g. The person you care for, family members or friend?

 

*How much do you feel your role as a carer affects your financial situation?

 

Care Group Category

 

Nature of Initial Enquiry

 

Carers Referral Form

"A carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support " (Carers Trust)