Section 1: About me
My name
Known as
Address
Address
Postcode
Email
Home phone number
Mobile phone number
Gender
DOB:
My relationship to the person I care for (e.g. mother, son, wife, brother, friend)
Section 2: Details of the person I care for and their home
Their name
Known as
Address
Postcode
Email
Home phone number
Mobile phone number
Gender
DOB:
If there is a key safe or alarm system how would someone get into the house in an emergency?
If telecare is used please give details of who responds to a call in the emergency contact section.
Are there any animals in the house?
If there are any animals at the house please give details below:
What type of animals are there at the house? How many animals are there? Where are the animals kept at the house? Are the animals a risk to strangers in any way? If so please describe the risk.
Care for more than one person? If you care for more than one person who would need to be contacted and/or looked after in an emergency please give their details below.
Their name
Known as
Address
Postcode
Email
Home phone number
Mobile phone number
Gender
DOB:
Where is their Emergency Plan kept?
Section 3: Where the person I care for might be if they are not at home.
Location 1
Place name
Description e.g. day service/care provider/supported living/your home
Address
Postcode
Contact name
Telephone number
Email address
Location 2
Place name
Description e.g. day service/care provider/supported living/your home
Address
Postcode
Contact name
Telephone number
Email address
Location 3
Place name
Description e.g. day service/care provider/supported living/your home
Address
Postcode
Contact name
Telephone number
Email address
Location 4
Place name
Description e.g. day service/care provider/supported living/your home
Address
Postcode
Contact name
Telephone number
Email address
Location 5
Place name
Description e.g. day service/care provider/supported living/your home
Address
Postcode
Contact name
Telephone number
Email address
Location 6
Place name
Description e.g. day service/care provider/supported living/your home
Address
Postcode
Contact name
Telephone number
Email address
Section 4: Specific information to ensure personalised care.
Is there anything else emergency services need to be aware of e.g. do they need a sensory object or toy, do they have particular likes and dislikes and/or morning/evening routines? Please indicate whether these needs are daily and/or longer term.
Section 5: GP and medical details of the person I care for
GP name
GP practice name
Address
Postcode
Landline phone
Cared for person‘s condition/diagnosis
Where is their medication kept?
Section 6: Other dependants in the home
Dependant 1
Name
Known as
Gender
DOB
Mobile phone number
Please give any information that is important for emergency services to know e.g. health / communication needs
Dependant 2
Name
Known as
Gender
DOB
Mobile phone number
Please give any information that is important for emergency services to know e.g. health / communication needs
Section 7: Emergency contacts
Emergency Contact 1
Name
Address
Postcode
Landline phone number
Mobile phone number
Email address
Relationaship to cared for person
Do they have access to the home?
Will they support the cared for person?
Which dependant will they support?
Which pets will they look after?
Do they respond to telecare calls?
Emergency Contact 2
Name
Address
Postcode
Landline phone number
Mobile phone number
Email address
Relationaship to cared for person
Do they have access to the home?
Will they support the cared for person?
Which dependant will they support?
Which pets will they look after?
Do they respond to telecare calls?
Emergency Contact 3
Name
Address
Postcode
Landline phone number
Email address
Mobile phone number
Relationaship to cared for person
Do they have access to the home?
Will they support the cared for person?
Which dependant will they support?
Which pets will they look after?
Do they respond to telecare calls?
Section 8: Care at home that is paid for
Agency 1
Agency name
Contact name
Address
Postcode
Landline phone number
Mobile phone number
Email address
Agency 2
Agency name
Contact name
Address
Postcode
Landline phone number
Mobile phone number
Email address
Section 9: Legal Responsibilities
First contact
Contact name
Responsibility
Address
Postcode
Landline phone number
Mobile phone number
Email address
Second contact
Contact name
Responsibility
Address
Postcode
Landline phone number
Mobile phone number
Email address
Section 10: Additional information
Additional information you wish to give (E.g. emergency plan for pets, additional contacts, additional needs of the person you care for.)
Section 11: Statements
If no, please say why in the box below.
Print name to indicate signature
Date completed/submitted
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