Register as a carer

Carer Details

Section

Address including postcode:

Care you provide:

Carers Signature: *

Enter full name

Carers assessment

A carers assessment is your opportunity to discuss with Carers Matters Norfolk what support or services you need. The assessment will look at how caring affects your life. You will be entitled to an assessment regardless of the amount or type of care you provide, your financial means or your level of need for support.

You don’t necessarily have to live with the person you are looking after or be caring full-time to have an assessment. You may be juggling work and care, and this is having a big impact on your life.

It is your choice whether you want to have a carers assessment or not. The assessment is not about judging how well you look after the cared-for person. By selecting ‘yes’ to a carers assessment you are consenting to us passing on your personal details to Carers Matters.

Would you like a carers assessment? *

Yes

No

How many hours a week you care?

How many people do you care for? And their relationship to you?

Please also complete the ‘details of person you look after’ section

Preferred method of contact:

Phone

Email

Preferred time to contact:

Are you happy for Carers Matter to leave a message with someone if you are not there?

Yes

No

Details of Person You Look After

Full Name:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Address including postcode (if different from above):

Telephone Number:

Relationship to you:

GP Details (if different from your own):

Please select which is appropriate:

I hereby give consent for the Practice to pass on information about myself to the Carer named above.

I hereby do not give consent for the Practice to pass on information about myself to the Carer named above.

Signature of person being cared for:

Enter full name

By signing this box, I give consent for the Carer named above to be recorded on my medical records.

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Carer Details

Section

Carers assessment

Details of Person You Look After