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Join The Carers Information Service
About You
Title
Name
First name
Last name
Date of birth
Gender
Address
Town
Postcode
Daytime phone number
Mobile phone number
Email (please provide your email address if you are happy to receive information by email)
Education & employment
Full time employment
Part time employment
Unemployed
Unable to work due to caring responsibilities
Retired
Full time student
Part time student
Other (please specify)
Education & employment - if you selected 'other' please describe here
Ethnicity
White English / Welsh / Scottish / Northern Irish / British
White Irish
Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black / African / Caribbean background
Arab
Any other ethnic group
Ethnicity - if you selected 'other' please describe here
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Does you GP surgery know you are a carer?
Some GP surgeries offer priority appointments and other carers support
Are you on the carers register at your GP surgery
Yes
No
Don't know
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If no / don't know, would you be happy for us to let your GP surgery know that you are a carer?
Yes
No
If your GP surgery knows you are a carer they may be able to offer you additional support, such as priority appointments.
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Your GP surgery
In order to let your GP surgery know you are a carer, we need to know their name and address.
Your GP (doctor)
GP address
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About The Person You Support
Please tell us about the person you support. If you support two people, please give us the second person's details on the next page. If you support more than two people, please complete the form only for the two people that need the most care.
Date of birth
What is your relationship to the person you support (for example are you their husband, daughter, neighbour)
Please tell us which town the person you support lives in
Bournemouth
Christchurch
Poole
Does the person you support live with you?
Yes
No
Please describe the needs of the person you support (tick all that apply)
Physical disability (under 65)
Learning disability
Older person
Dementia
Mental health problems
Drug/alcohol problems
Sensory problems (sight, speech, hearing)
Other (please describe in box below)
Other
Ethnicity of the person you support
White English / Welsh / Scottish / Northern Irish / British
White Irish
Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black / African / Caribbean background
Arab
Any other ethnic group
Ethnicity - if you selected 'other' please describe here
Do you support another person?
Yes
No
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About The Second Person You Support
Please tell us more about the second person you support. If you support more than two people, only complete this form for the two people that need the most care.
Date of birth
What is your relationship to the person you support (for example are you their husband, daughter, neighbour)
Please tell us which town the person you support lives in
Bournemouth
Christchurch
Poole
Does the person you support live with you?
Yes
No
Please describe the needs of the person you support (tick all that apply)
Physical disability (under 65)
Learning disability
Older person
Dementia
Mental health problems
Drug/alcohol problems
Sensory problems (sight, speech, hearing)
Other (please describe in box below)
Other
Ethnicity of the person you support
White English / Welsh / Scottish / Northern Irish / British
White Irish
Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black / African / Caribbean background
Arab
Any other ethnic group
Ethnicity - if you selected 'other' please describe here
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Carer's Assessment - Help for You
A carer's assessment is time to look at your needs and how you could be supported. This might be through advice, information or by providing short breaks. It may increase the number of ways you can access support.
Have you had a carer's assessment through Adult Social Care Services?
Yes
No
Would you like a carer's assessment?
Yes
No
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Carers Assessment Referral
In order to refer you for a Carers Assessment, we need to take the following details.
Name of the person you support
The GP surgery and address of the person you support
Do you support another person?
Yes
No
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Carers Assessment Referral
Please provide the the following details for the second person you support
Name of the person you support
The GP surgery and address of the person you support
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Thank you!
Thank you for taking the time to complete this form. We hope you will find the Carer's Information Service useful.
How did you find out about the Carers Information Service?
Carers Team
CRISP website
Carers Team stand at an event (please tell us which event in the box below)
Leaflet
GP (doctor)
Other (please describe below)
If you selected 'other' or want to tell us more about how you found out about the Carers Information Service, please tell us here
Any personal information you provide us with, will be held and used in accordance with the Data Protection Act 2018. If you would like to find out more information about how we will use your information, please see our Privacy Notice here: crispweb.org/privacy-notice.aspx
I agree
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