Fillable Carer Self Assessment Form Carer Self Assessment Form A4 New.pdf

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Carer Self Assessment Form Carer Self Assessment Form A4 New.pdf

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Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
Carers Self Assessment
To be returned to:
Inverclyde Carers Centre
68-70 Cathcart Street
Greenock
PA15 1DD
01475 735180
enquiries@inverclydecarerscentre.org.uk
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
ABOUT YOU AS A CARER
NAME
ADDRESS
TELEPHONE
EMAIL
BEST CONTACT METHOD
DATE OF BIRTH
GENDER
ECONOMIC STATUS
Please score out of 10
(1 being worst it could be,10 being as good as it could be)
HOW INFORMED ARE YOU ABOUT SUPPORT AND
SERVICES AVAILABLE FOR CARERS?
HOW IS YOUR PHYSICAL AND EMOTIONAL WELLBEING?
HOW CONFIDENT ARE YOU IN YOUR CARING ROLE?
HOW INVOLVED IN PLANNING AND SHAPING THE
SERVICES REQUIRED FOR YOU AND THE PERSON YOU
CARE FOR DO YOU FEEL?
HOW ABLE ARE YOU TO COMBINE CARING
RESPONSIBILITIES WITH LIFE OUTSIDE?
HOW DISADVANTAGED OR DISCRIMINATED AGAINST DO
YOU FEEL BECAUSE OF CARING? (INCLUDING
FINANCIALLY)
How did you find out about us? ______________________
Is there something in particular you want to know about?
__________________________________________________________
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
Using your personal information
The highlighted information is essential for registration, other information
is optional but will help us personalise any information, advice and
support we provide. If you would rather discuss this please leave it blank
and one of our Carer Support Workers will contact you. Staff will process
data about Carers on a regular basis such as carrying out registrations,
completing Carers Self Assessments, dealing with enquiries, or arranging
appointments internally or externally via a third party organisation. Further
detail is available within the Data Protection Policy.
Media consent
Inverclyde Carers Centre produce a range of materials to tell Carers
about our services. From time to time we take photographic images
(moving and still) and use case studies which can include personal data
(such as name and/or diagnosis where appropriate and consented to) to
demonstrate the difference our work makes to Carers in Inverclyde.
By completing this form, you give us full permission to use these images
and any personal information you supply to us in our media applications,
which reasonably promote or advertise Inverclyde Carers Centre’s work.
(This may include our printed publications; adverts; audiovisual and
electronic materials; media work; display materials; and any other media we
may use in the future.) The images will not be used for any other purpose.
Please state here if there are any ways in which you do NOT want
us to use photo(s) of you:
I understand that in completing this staff from Inverclyde Carers
Centre will contact me to provide, information, support or advice
which may benefit me as a Carer.
Signed _________________________________ Date ____________
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
PHYSICAL AND EMOTIONAL WELLBEING?
Do you have any illnesses/conditions? __________________________
Are you disabled? __________________________
I have concerns about the impact caring has on my physical
health
I have concerns about my own safety
I have concerns about the impact caring has on my mental health
or well being
Please give additional information if you would like to discuss these
further
__________________________________________________________
Has your caring role affected your relationship with the person you care
for? If yes, can you explain in what way?
__________________________________________________________
Has your caring role affected your relationships with other people? If yes,
can you explain in what way?
__________________________________________________________
GP Name: ______________________ Practice: ________________
Would you like to be added to your GP’s Carer Register?
__________________________________________________________
I feel listened to and supported emotionally
I have contact with others in similar caring situations
I manage to keep up with friends and family
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
YOUR CONFIDENCE IN CARING
We have included space for two of the people you care for.
Please let us know if you care for more than this.
How many hours a week do you spend
car
ing for other people?
1-19
20-34
35-49
50 or more
What is your relationship to
the
first
person you care for?
How long have you been
caring for them?
Name:
Address:
Post Code:
Illness/Conditions:
Date of Birth:
GP Name and Practice:
Does this fluctuate due to the person’s condition? (they may be well for
long periods)
__________________________________________________________
Are there things you feel you need to learn or get information about to
help you in your caring role?
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
It will be helpful if you can give details of what your caring roles involve.
There are many different caring roles, some Carers provide many
different types of support, others provide quite specific support.
Type of care you
provide
What does this typically involve?
Supervision
e.g. not leaving them alone, attending appointments with
them
Emotional Support
e.g. listening and reassuring
Personal Care
e.g.prompting or assisting with washing or dressing
Domestic Chores
e.g. housework and shopping
Business and
Financial Matters
e.g. dealing with bills and banking
Physical Support
e.g. physically helping someone out of their chair or bed
Other
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
What is your relationship to
the
second
person you care
for?
How long have you been
caring for them?
Name:
Address:
Post Code:
Illness/Conditions:
Date of Birth:
GP Name and Practice:
Does this fluctuate due to the person’s condition? (they may be well for
long periods)
__________________________________________________________
Are there things you feel you need to learn or get information about to
help you in your caring role?
__________________________________________________________
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
It will be helpful if you can give details of what your caring roles involve.
There are many different caring roles, some Carers provide many
different types of support, others provide quite specific support.
Type of care you
provide
What does this typically involve?
Supervision
e.g. not leaving them alone, attending appointments with
them
Emotional Support
e.g. listening and reassuring
Personal Care
e.g.prompting or assisting with washing or dressing
Domestic Chores
e.g. housework and shopping
Business and
Financial Matters
e.g. dealing with bills and banking
Physical Support
e.g. physically helping someone out of their chair or bed
Other
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
INVOLVED IN PLANNING AND SHAPING SERVICES
Staff involved _________________ Job Title/Organisation:____________
Do you feel involved by care staff in the planning and care of the person
you look after?
If yes, in what way? __________________________________________
If no, in what way? __________________________________________
What are your thoughts on the level and amount of support you are
providing?
__________________________________________________________
Do you look after the financial affairs of the person you care for?
Do you need advice about this?
Do you have plans in place to ensure the person you care for is looked
after in the event of a short term emergency?
__________________________________________________________
Do you have plans in place to ensure the person you care for is looked
after should you be no longer able to care for them?
Do you have this in
place?
Would you like
information?
Appointeeship
Power of Attorney
Guardianship
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
LIFE OUTSIDE CARING
I get a regular break from caring
I get a break from caring but not regularly
I don’t get any break from caring
Do you get a chance for leisure or social activities?
__________________________________________________________
What would you like to do, but don’t get time for?
__________________________________________________________
Would you like to develop skills or interests in other areas of life, if so
what?
__________________________________________________________
As well as caring responsibilities what other responsibilities do you have
and how much of your time does this take up?
If you are working…
Does your employer know that you’re a Carer?
Do you feel supported as a working Carer?
Do you know your rights as a working Carer?
Would you like help to develop your skills to change your career?
If you are not working at the moment …
Would you like help to find work?
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
DISADVANTAGED OR DISCRIMINATED
Have you had a benefits check?
If yes, when? ____________________________
If not, would you like one? ____________________________
Are you currently experiencing disadvantage or discrimination, including
financial hardship, due to your caring role?
Have you had a Carers Assessment before?
If yes, when? ______________________________
Would you prefer to be referred to Inverclyde Health and Social Care
Partnership for a full Carers Assessment? Yes/No
Inverclyde Carers Centre Ltd is a Company Ltd by guarantee no 312596 – Scottish Charity NoSC038583
TO BE COMPLETED FOLLOWING DISCUSSION BETWEEN CARER SUPPORT WORKER AND CARER
ACTION PLAN
PRIORITY AREA
SCORE
ACTION TO IMPROVE OR
SUSTAIN
BY
WHO
BY
WHEN
COMPLETION
DATE
SCORE
BETTER INFORMED
HEALTHIER
CONFIDENCE IN CARING
FEELING IN
VOLVED
HAVING A LIFE OUTSIDE
NOT DISADVANTAGED
OR DISCRIMINATED
AGAINST
Carer Self Assessment Form 300617
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Completed 7 July 2020

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