Carer Self Referral - Carers' Support East Kent

Home
About
Carers
Professionals
Get Involved
News
What’s on for Carers
Contact

0300 302 0061

support@carersek.org.uk

Donate

Home
About
Carers
Professionals
Get Involved

Carer stories
News
- Carers’ News
What’s On
Contact

Complete the form below to access information and support

If you look after a relative or friend, who due to physical or mental illness, age related difficulties, disability or addiction, cannot manage without your support, you are a Carer, and our information and support services are for you. (You may not think of yourself as a Carer).

Being a Carer

Being a Carer can be both rewarding and challenging. As a Carer, it’s important to look after your own health and well-being. We are here to support you.

Everyone’s experience as a Carer is different. As an example, you might help someone with:

personal things like getting washed, dressed or eating
moving about or turning at night
medication
shopping, laundry or cleaning
completing forms
managing money

If you would like information and support to guide you through this, please complete our form below and we will be in touch.

Our privacy notice is available here.

About you

Name *

First

Last

Date of birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Preferred pronouns *

Landline number *

Mobile number *

Email address *

May we leave voicemails on the phone numbers you've provided? *

How do you prefer us to contact you, for example landline phone, mobile phone, text, email? *

Is there anything else we need to be aware of when contacting you? *

How many hours does the Carer provide care per week? *

1-7 hours
8-14 hours
15-21 hours
22-28 hours
29-35 hours
36-42 hours
43-49 hours
50+ hours

Your GP practice *

Does your GP practice know that you are a Carer? *

Yes
No
I don't know

About the person / people you care for

Name *

First

Last

The 1st person the Carer supports date of birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Their GP Practice (if known) *

Do you care for another person? *

About the 2nd person you care for

Name of 2nd person *

First

Last

Date of birth of 2nd person *

Address of 2nd person *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Their GP Practice (if known) for the 2nd person *

About your caring role

1. Who do you care for and what conditions do they have? *

2. How do you support the person / people you care for? * *

3. Do you or the person /people you care for have support from any other services? *

4. Do you have any health issues (physical / mental health) and / or do you feel caring affects your health and wellbeing? *

5. Do you need any support around finances? *

6. Is there anything you are finding challenging in your caring role? *

7. Is there anything you would like to ask us in relation to your caring role? *

Kent and Medway Carers' Emergency Card
As a Carer, you may often worry about what would happen to the person you care for if you suddenly became ill or were involved in an accident. By carrying a Kent and Medway Carer’s Emergency Card, someone close to you can be contacted in those situations so that the person you care for can be supported while you are unavailable. We can send you one of these Emergency Cards if you would like one. We can also support you to implement a contingency plan.

Would you like a Kent and Medway Carers' Emergency Card? *

Equality information
Carers' Support East Kent wants to meet the aims and commitments set out in our equality policy. This includes not discriminating under the Equality Act 2010, and building an accurate picture of the make-up of the Carers whom we serve. The information you provide will be kept confidential and will be used for monitoring purposes and to help in our understanding of how we may best support you personally.

What is your sex? *

Female
Intersex
Male
Prefer not to say
Unknown

Is the gender you identify with the same as the sex you were assigned at birth? *

Yes
No
Prefer not to say

What is your sexual orientation? *

Heterosexual
Bisexual
Gay / lesbian
Prefer not to say

What is your marital status? *

Married or in a civil partnership
Not married or in a civil partnership
Separated
Widowed
Prefer not to say

What is your ethnicity? (ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong) *

Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: any other Asian background
Black/Black British: African
Black/Black British: Caribbean
Mixed: White and Asian
Mixed: White and Black/African
Mixed: White and Black/Caribbean
Other: Arab
Other: Any other ethnic group
White: English/Welsh/Scottish/Northern Irish/British
White: Gypsy, Romany, or Traveller
White: Irish
White: any other White background
Prefer not to say

What is your religion or belief? *

Buddhist
Christian
Hindu
Muslim
Sikh
Other
No religion
Prefer not to say

If you identify as disabled, please complete: *

Autism
Dementia
End of Life
Frailty
Learning disability
Long standing health condition or illness
Mental Health need/condition
Physical/Mobility impairment
Sensory impairment (dual - hearing and visual impairment)
Sensory impairment (hearing impairment)
Sensory Impairment (visual impairment)
Substance Misuse
Not applicable
Prefer not to say

Do you need an interpreter? *

British sign language (BSL)
Spoken work
Not applicable
Prefer not to say

How did you hear about us? *

Already known to you as a Carer
Another Carer
Community Navigator
Family Member / Friend
Google / Web Search
Leaflet
Professional - Education
Professional - Health
Professional - Social Care
Voluntary Organisation

We may identify other services / support that may be of benefit to you. If a referral is needed, we will ask your consent before making a referral.

The lawful basis used for processing data is legitimate interest. In an emergency situation or where there is a risk of serious harm, we may need to / be required by law to share information without your consent.

Please confirm that you have read and understood the above *

I confirm that I have read and understood the above.

Please confirm that you have read and understood our privacy notice *

I confirm that I have read and understood the privacy notice

Would you like a copy of this form emailed to you? *

Message

1 in 9 people

in Kent

are Carers

Caring will

affect us all

at some point in our lives

If you’re a Carer,
looking after your own

health and well-

being is important

Carers’ Support East Kent is a charity that provides Carers with the information and support they need. Our services are available to people looking after a relative or friend, who due to physical or mental illness, age related difficulties, disability or an addiction, cannot manage without their support.

Privacy Notice

Terms & Conditions

Carers’ Support East Kent
Innovation House
Discovery Park
Ramsgate Road
Sandwich
Kent CT13 9ND

T: 0300 302 0061
M: 07545 916214
E: support@carersek.org.uk

Company Limited by Guarantee no. 07213672
ICO Registration no. Z2453970
Registered Charity no. 1136904