Are you referring yourself or someone else?*

First Name*

Surname*

Address line 1*

Address line 2

Town*

Postcode*

Home phone number

Mobile Telephone No.*

Primary Email Address*

Gender*

Date of Birth*

Ethnic Group*

Do you have a disability?*

Do you live with the person you care for?*

How long has the carer been providing care?

Care Hours Per Week (Typical)

First Name*

Name*

Address line 1*

Address line 2

Town*

Postcode*

Gender*

Date of Birth*

Ethnic Group*

What is the Cared For person’s condition?*

Parent Phone Number

Parent Email Address

How often do you clean/ tidy because of your caring role?*

How often do you make meals for the person you care for or the family? (Includes ordering online or going to shops)*

How often do you do the household laundry.*

How often do you book/attend appointments for the cared for person?*

How often are you carrying out direct physical/personal care for the cared for person*

How often are you giving meds, reminders, collecting prescriptions*

How often are you there to talk, calming, offering supporting feelings*

How often are you monitoring for risk of falls, seizures, confusion, etc.*

How often are you babysitting, doing school runs, helping with homework*

How often are you helping the cared for person move around.*

How often are you booking taxis, lifts, accompanying on public transport*

How often are you managing finances, benefits, budgeting, official forms.*

How often are you speaking on behalf of the cared for to professionals.*

How often are you providing night time support that affects your sleep.*

Is there anything else you'd like to share with us?