Carers Self Assessment

Portsmouth Carers Centre

Introduction

A carer is someone who supports someone else in an unpaid capacity who could not cope without their help. A carer's assessment is an opportunity for you to think about and discuss your needs as an individual. It is a chance to consider the impact your caring role has on your wellbeing and other important aspects of your life.
You can fill this out yourself (this is known as a self-assessment) or you can contact the Carer's Centre if you would like to speak to someone.

Portsmouth City Council will process your personal information in accordance with the Data Protection Act 1998. The personal details provided by you will be held on a database and where the law allows, may be shared with other departments within the council to update the details they hold about you. The council may also be required to disclose personal information to other Local Authority departments and third parties (such as the police, Audit Commission or Department for Work and Pensions) for the purposes of preventing or detecting crime, fraud or apprehending or prosecuting offenders.

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* 1. Carer's details:

Full name:

Date of birth:

Address:

Postcode:

Tel no:

Mobile no:

E-mail:

Preferred method of contact and best time of day

GP name:

GP address:

NHS Number:

Your relationship to the person you care for:

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* 2. Details of person being cared for:

Full name:

Date of birth:

Address:

Postcode:

Telephone number:

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* 3. We may share information with other agencies to help us provide you with the right support. On this basis is there any anyone you don't want us to share information with? If so please detail here.

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* 4. Background - tell us about your caring role (e.g. what support do you provide, what does your average day look like, what impact does your caring role have on you? Does anyone help you with your caring role? Is there anyone else you care for?)

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* 5. Are there any young people under 18 in your household who help provide care, or are affected by your caring role?

Yes

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* 6. Tell us about your needs as a carer (What might make things easier in your caring role? What matters to you?)

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* 7. What would you do in an emergency if were suddenly unable to carry out your caring role?

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* 8. We recognise that looking after someone can be difficult. Are you willing and able to continue the support you provide?

Yes

Comments:

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* 9. Do you want a copy of your assessment and support plan?

Yes