Section 1: About me
My full name
Known as
Address (including postcode)
Contact number
DOB:
My relationship to the person I care for (e.g. Mother, Son, Wife, Brother, Friend)
Communication needs, (e.g large print, translator)
If interpeter is needed, please specify which language
Section 2: Details of the person I care for and their home (if you care for more than one person please use a seperate form for each)
Their full name
Known as
Address (including postcode)
Contact number
DOB:
Communication needs, (e.g large print, translator)
If an interpreter is needed, please specify which language
If yes, what is the keysafe code?
If telecare (falls alarm etc) is used please give details of who responds to a call?
Section 3: Where the person I care for might be if they are not at home.
Day
Time
Location
Day
Time
Location
Section 4: GP and medical details of the person I care for
Doctors name and surgery
Contact Number
Cared - for person's medical condition(s) / diagnosis / allergies
If 'Yes', where is their medication kept?
Is there a ‘Message in a bottle’ and where is it kept?
Section 5: Legal Responsibilities
First Contact
Name
Responsibility
Address (including postcode)
Contact Number
Second Contact
Name
Responsibility
Address (including postcode)
Contact number
Section 6: Emergency contact for unpaid carer (please provide emergency contacts for yourself)
Contact 1
Name
Address (including postcode)
Contact Number
Relationaship to cared - for person
Do they have access to the home?
Will they support the cared for person?
Which pets will they look after?
Contact 2
Name
Address (including postcode)
Contact Number
Email address
Relationaship to cared for person
Do they have access to the home?
Will they support the cared for person?
Which pet(s) will they look after?
Section 7: Specific information of care and support you provide to cared for person(s)
Personal Care Provided (e.g. support with showering, washing, toileting, dressing etc):
Meal Support Provided (e.g. shopping, cooking food, preparing meals, heating food in microwave, ensuring they are eating):
Medication Support Provided (e.g. administering, applying etc):
Mental health and behavioural support provided (e.g. any specific triggers, likes and dislikes, anything to be aware of):
Paid for care that is provided (e.g. care agency, companion service, sitting service, respite etc):
Section 8: Additional information
Is there anything else that you wish to tell us?
Section 9: Statements
If no, please say why in the box below.
Print name to indicate signature
Date completed/submitted
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