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 employmentPart time employmentUnemployedUnable to work due to caring responsibilitiesRetiredFull time studentPart time studentOther (please specify)
Education & employment - if you selected 'other' please describe here
Ethnicity
Ethnicity - if you selected 'other' please describe here

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
YesNoDon't know

If no / don't know, would you be happy for us to let your GP surgery know that you are a carer?
YesNo

If your GP surgery knows you are a carer they may be able to offer you additional support, such as priority appointments.

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

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
BournemouthChristchurchPoole
Does the person you support live with you?
YesNo
Please describe the needs of the person you support (tick all that apply)
Physical disability (under 65)Learning disabilityOlder personDementiaMental health problemsDrug/alcohol problemsSensory problems (sight, speech, hearing)Other (please describe in box below)
Other
Ethnicity of the person you support
Ethnicity - if you selected 'other' please describe here
Do you support another person?
YesNo

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
BournemouthChristchurchPoole
Does the person you support live with you?
YesNo
Please describe the needs of the person you support (tick all that apply)
Physical disability (under 65)Learning disabilityOlder personDementiaMental health problemsDrug/alcohol problemsSensory problems (sight, speech, hearing)Other (please describe in box below)
Other
Ethnicity of the person you support
Ethnicity - if you selected 'other' please describe here

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?
YesNo
Would you like a carer's assessment?
YesNo

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?
YesNo

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

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 TeamCRISP websiteCarers Team stand at an event (please tell us which event in the box below)LeafletGP (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