Stirling Carers Centre
This form is for use by people who provide unpaid care to a family member, friend or neighbour who requires assistance because of illness, disability or because they are elderly and /or frail. It can also be used by staff working in a caring environment e.g. Social Work, Carers Centre.
The form is useful in two ways. Firstly it can help Carers identify the effect the caring role has on the Carer’s life, the help and support already provided and linking these to the needs of the cared for person and how they are to be met. It can identify how responsibility to provide care could be shared by the Carer and other support agencies.
Secondly, the form will provide important information to a local authority social worker, or other professional, for this Carer’s Assessment as provided for in the Community Care and Health (Scotland) Act 2002. The social worker or other care manager who completes the Carer’s Assessment will work with the Carer to plan and arrange appropriate services to meet their needs and to support the Carer.
The form can be filled in by the Carer alone or by the Carer and a social worker / other professional together.
Carers may also involve a friend, relative or anyone else whose support they value when completing the form, or at other stages in the assessment process, if they wish.
To assess what support Carers might need, it is necessary to ask questions about sensitive matters and Carers are requested to answer as fully as possible.
All information will be treated in strict confidence and will not be shared with any third party without the Carer’s consent.
In the following questions please tick all the boxes which apply.
11/07
1. Carer Personal Details
Title:___ First Name(s):______Surname:______Contact Telephone Number(s) Home:______
Work:______Mob:______
Address:______
______
______Postcode:______
Date:______
Age range:
Please circle: 18 – 24 25 – 39 40 – 64 65 – 74 75+
Are you in employment? Full Time Part Time Not at All
Has your caring disrupted your employment Yes No
Are you in Education? Full Time Part Time Not at All
Would you like to be in employment? Yes No
Education? Yes No
Ethnic Origin:Caribbean African Chinese Other Black Other White
(specify) (specify)
Pakistani Indian Bangladeshi Other Asian Other
(specify) (specify)
Mixed Traveller White British
(specify) (specify) (specify)
Do you need help with an interpreter for a language other than English?
Yes No If yes, which language? ______
Do you need help with an interpreter due to a sensory disability? Yes No
If yes what type of help do you require? ______
How many people, including yourself and children, live at the above address? __
Do any of them help care for the person/people being cared for? Yes No
(e.g. children who are caring, partner, etc)
If yes, please request their agreement before giving their details below:
(1) Name: ______
Date of Birth: ______
(2) Name: ______
Date of Birth: ______
2. Details of the Person/People You Care For
Initials only: ______/ Initials only:______
Age range: Please circle:
Under 18 18 – 24 25 – 39 40 – 64 65 – 74 75+
Do you live in the same house as the person/people you care for? Yes No
If yes who with:______
If ‘No’, what type of accommodation do they live in?
______lives in: / ______lives in:Rented accommodation
Owner/occupier
Residential accommodation
What is your relationship to the person/people you care for? (e.g. are they your father / mother, your son / daughter etc):
(1) ______
(2) ______
3. Health (Please use separate sheet if necessary)
What health problems does the person/people you care for have?
Health problems of (initials only) ______/ Health problems of (initials only): ______Do YOU have any health problems of any kind? If so, please describe them as fully as possible. (For example you may have a bad back or you may feel under stress)
4. Help in the Home
Does the person/people you care for have any physical or emotional problems?
Yes No
How many days a week do you provide care (Please circle) 1 2 3 4 5 6 7
On the days that you provide help and care, how long do you spend caring?
In my caring role for:(initials only)
______
(Please tick and/or describe) / In my caring role for:
(initials only)
______
(Please tick and/or describe)
Up to 4 hours
4-8 hours
8-12 hours
More than 12 hours
What help do you provide for the person/people you care for?
Some examples ofthe help I provide
may be: / The help I provide for:
(initials only)
(Please tick and/or describe) / The help I provide for
(initials only)
(Please tick and/or describe)
Getting in/out of bed
Bathing
Dressing/Undressing
Help with continence
Toileting
Washing
Cooking
Housework
Medication
Eating
Cleaning
Laundry
Shopping
Gardening
Emotional Support
Keeping safe or supervising
Help to communicate
Help with paperwork
Help with transport
Help controlling challenging
Behaviour
Other types of help
you provide (please
specify)
If you provide care during the night, is this?
During the night in mycaring role for : (initials only)
______
(Please tick and/or describe) / During the night in my
caring role for :(initials only)
______
(Please tick and/or describe)
Every night
Some nights
As and when required
What help do you get looking after the person/people you care for?
The help I get in mycaring role for:
(initials only)
______
(Please tick and/or describe) / The help I get in my
caring role for:
(initials only)
______
(Please tick and/or describe)
Personal care
(e.g. dressing,
washing etc)
Respite care
(short break)
Domestic help
(e.g. cleaning,
shopping etc)
Day Centre
Equipment
Health Services
(e.g. nursing, podiatry)
Other types of help
you receive (please
specify)
Who helps? / I get help in my caring role
for: (initials only)
______from:
(Please tick and/or describe) / I get help in my caring role
for: (initials only)
______from:
(Please tick and/or describe)
Doctor
District Nurse
Occ Therapist
Care Manager
Relatives
Private Agency
Crossroads
Neighbours
Friends
Carers Centre
No help at all
Other
(please specify)
Would you like some extra help with caring? Yes No
What types of help would be most helpful to you?
For (initials only):______The type(s) of help that will be most
useful to me are: / For (initials only):______
The type(s) of help that will be most
useful to me are:
If you could get help with only one task, which one would it be?
For (initials only):______If I could get help with only one task
it would be: / For (initials only):______
If I could get help with only one task
it would be:
If that task were taken care of, which would be the next task you would like help with? (this is to help you draw up a list of priorities)
For (initials only):______If that task were taken care of my next
priority would be: / For (initials only):______
If that task were taken care of my next
priority would be:
5. Information About You
When was the last time you had a whole day to yourself to do as you pleased?
Do you feel you are getting enough sleep? Yes No
Do you feel your health has become worse as a result of your caring role? Yes No
What are your hobbies or interests?
Are you able to pursue them? Yes No
Do you feel that you have a choice about providing care? Yes No
Do you ever feel at risk because of your situation? Yes No
If there is anything you would like to change about your situation, what would it be?
Have you received information about benefits entitlement? Yes No
Would you like to receive information? Yes No
6. Continuing to Care
Do you feel that you can go on caring with your present level of support?
Yes No
If yes, do you think this is likely to change in the future? Yes No
Do you have any comments with regard to any of the two questions detailed above:
Are there any other issues you wish to identify?
Which of the following services would help you to continue caring?
The services that will help mein my caring role
for (initials only):
______are:
(Please tick and/or describe) / The services that will help me
in my caring role
for (initials only):
______are:
(Please tick and/or describe)
Help with personal care
(e.g. dressing/
toileting/washing)
Help with nursing care
Help with
shopping/cleaning
Meal provision service
Adaptations to home
(e.g. stairlift, wheelchair
Access etc)
Place in Day Centre
Respite in the home
Temporary place for
a relative or friend
in a care home
Permanent place for
a relative or friend
in a care home
Counselling/talking
To someone
Support group
Advocacy
(someone to talk
on your behalf)
Information on
services & support
available
Social contact
Training (e.g. moving
& handling/stress
management)
Other: (Please specify– e.g. Short break for you for 2
hours or short break for
cared for in home or
elsewhere etc)
If you would like a formal (statutory) Community Care Assessment, please indicate in the box and a member of social work staff from Stirling Council
will be asked to contact you.
Has the person you care for had a Community Care Assessment?
Yes No Don’t Know
Does the person you care for agree to a Community Care Assessment/Re-assessment being carried out?
Yes No
Is there any specific information you do not wish me to share with anyone else?
Yes / No - Give details______
Consent to sharing information:Ø I agree to information in this form about my caring situation
being shared with the social work department of Stirling Council,
Carers Centre and any other relevant agency.
(You do not need to give your consent)
Please tick:
Ø There may be information in this form which will be helpful to your
GP. Please give your consent to a copy of this form being sent to
your GP by giving the details below (you do not need to give
your consent).
Please tick:
Name of GP:______
Practice:______
Under the Data Protection Act (1998) your details will not be used for
anything other than what you have indicated above.
Signature:______(Carer) Date:______
Completed by:______(signature)
Job Title:______
Date sent to Social Work: ______
Date sent to Carers Centre: ______
Ensure the Agreed Outcomes on Page 12 and 13 are completed and a copy given to the Carer.
Agreed Outcomes/Possible Action Points:
This form should be completed with the Carer and a copy given to him/her.
What Carer Centre services are required?
√Emotional support
Advocacy
Relaxation sessions
Training
Time Out Group
Welfare benefit checks/form filling
Coffee mornings
Young Carers
Other:
What statutory services are required?
For (initials only):______ / For (initials only):______ /√
What other services required?
For (initials only):______ / For (initials only):______ /√
Is this caring situation a priority for respite? Yes ð No ð
For (initials only) ______This situation is a priority for respite because: / For (initials only):______
This situation is a priority for respite because:
Which agencies the Carer has been referred to:
For help with the caring situation with regardTo (initials only):______this carer has
been referred to: / For help with the caring situation with regard
To (initials only):______this carer has
been referred to:
Details of any specific information the Carer does not want shared with anyone:
______
______
Print Name: ______Contact Number: ______
Job Title: ______
Signature: ______Date: ______
NOTES:
When completed, this form should be returned to either:
Stirling Carers Centre,
FREEPOST SCO735
Stirling
FK8 1BR
(no need for a stamp)
OR
Care Management Service
Stirling Council
Drummond House
Wellgreen
Stirling
FK8 2EG
OR
The District Nurse
at your local
GP Practice
1