Tell us more about you - Carers' Support East Kent

Name *

First

Last

Date of birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Do you have a landline phone? *

Yes I have a landline phone
No landline phone

Landline number *

Do you have a mobile phone? *

Yes I have a mobile phone
No mobile phone

Mobile number *

Do you know your email address? *

Yes I have an email address
No email address

Your email Address *

Do you know your NHS number? *

Yes I know my NHS number
No I don't know my NHS number

Your NHS number *

How many hours do you provide care to the person that you care for per week? *

1a. Please tell us the name of the person that you care for *

First

Last

1b. What conditions does the person you care for have? *

2. How do you support the person that you are caring for? *

3. Please list any existing services supporting you *

4. Do you give consent for us to contact the services supporting you on your behalf *

Yes I consent for you to contact the services supporting me on my behalf
No I do not consent for you to contact the services supporting me on my behalf

5. How is your own physical health? (please give details) *

6. If you feel there is a risk of your physical health deteriorating due to your caring role, please give details *

7. How is your own emotional wellbeing / mental health? Please give details *

8. If you feel there is a risk of your wellbeing / mental health deteriorating due to your caring role, please give details *

9. If you need any financial support or help to access benefits, please give details *

10a. Does your caring role make it difficult to shop for and prepare adequate meals for yourself and your family? *

Yes my caring role makes it difficult to shop for and prepare adequate meals for myself and my family
No my caring role does not make it difficult to shop for and prepare adequate meals for myself and my family

10b. Please give details of how your caring role makes it difficult to shop for and prepare adequate meals for yourself and your family *

11a. Does your caring role make it difficult to keep your home clean and safe? *

Yes my caring role makes it difficult to keep my home clean and safe
No my caring role does not make it difficult to keep my home clean and safe

11b. Please give details of how your caring role makes it difficult to keep your home clean and safe *

12. What would most improve your wellbeing or quality of life as a Carer? *

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 so that the person you care for can still receive help if you became unavailable.

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

Yes I would like a Kent and Medway Carers' Emergency Card
No I do not want a Kent and Medway Carers' Emergency Card

14. What is the name of your GP surgery? *

15. Does your doctor know that you are a Carer? *

Yes my doctor knows I'm a Carer
No my doctor doesn't know I'm a Carer
I don't know if my doctor knows I'm a Carer

16a. May we leave voicemails (and is it safe for you) on the phone numbers you've provided if we can’t reach you by phone? *

Yes please leave voicemails (it is safe for me) on the phone numbers I've provided if you can’t reach me by phone
No

16b. What times / days work best for you for us to contact you? *

16c. How do you prefer us to contact you, for example landline phone, mobile phone, text, email? *

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.

17. What is your sex *

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

Yes
No
Prefer not to say

19. What is your sexual orientation? *

Heterosexual
Bisexual
Gay / Lesbian
Prefer not to say

20. What is your marital status? *

21. What is your ethnicity? *

22. What is your religion or belief? *

23a. Do you identify as having a disability? *

Yes
No
Prefer not to say

23b. Please indicate your main disability *

24. Interpreting *

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

23. How did you hear about us? *

Consent

External referrals. In order to refer you to external organisations on your behalf, we will always ask for your consent before doing so. The only exception to this would be if there are any safeguarding risks or issues, any other time we will always ask for your consent first. Is this all OK with you? *

Yes
No

Privacy notice

25. Please tick to confirm that you have read and understood our privacy notice *

I have read and understand the Carers' Support East Kent privacy notice.

Tell us more about you.

Consent

Privacy notice