CARER’S SELF ASSESSMENT QUESTIONNAIRE

You are a carer if you provide unpaid care and support for a partner, relative, friend or neighbour on a regular basis because they are ill, frail or disabled.

Confidential information about you and the person you care for.

Date:

Section A: General details

Please tell us about you and the person you care for

About You
First Name: Last Name:
Address:
Postcode: Phone #:
Are you under 18 years of age? Yes No
About the person you care for
First Name: Last Name:
Date of birth:
If they do not live with you please provide:
Address:
Postcode: Phone #:
Their relationship to you (e.g. son, mother, friend etc.)
Have they had an assessment from Social Services? Yes No Not sure
What do you do as a carer?
How does this affect your life?

SectionB: Services and support

Please indicate which services, if any, you would like to support you

Emotional support for you
Q: Do you want to share how your life is affected by your caring role, and get help in thinking things through?
Yes No
Your GP can help you access various counselling services or you can contact:
The Wpf counselling servicewhich offers one to one counselling and a support group.
Where? Lighthouse, Ladbroke Grove, W11 (for the one to one sessions) and the Central Library Meeting Room, Hornton St, W8 (for the group sessions). To make a referral to the service, ring 020 7378 2007 or email
Support in your caring role
Q: Do you need to feel more confident about moving and handling the person you care for?
Yes No
The Injury Prevention Service can help you. It provides training in moving and handling the person you care for so as to minimise the risk of injury.
Where? Assessments and training are carried out in the home. To discuss a referral to the service, ring 020 7349 3240.
Advice and help with benefits
Q: Do you want help to see what financial benefits you may be eligible for?
Yes No
The Citizens Advice Bureau can help you check what you may be entitled to, and help with making claims.If you think you are notreceiving all the benefits you are entitled to please contact your local adult services team and ask for a referral to the income maximisation service.
Social servicesline: 020 7361 3013
Housing Advice Service
Q: Do you want confidential help and independent housing advice?
Yes No
HASKC provides advice, casework and advocacy in all areas of housing.
Where? A telephone advice line Monday to Friday 10.30am to 3.00pm on 020 8996 8900 or 0207 373 6262. A home visit service for people who cannot attend the drop-in sessions due to health or mobility issues. To arrange a visit please call 020 8996 8900.

Section C: You and your caring role

In this section please select the option that best describes how much support you provide (Part A) and then the impact this has on you (Part B).

For Part B tick the box using the following scale of 1 to 5 (1 being no impact – 5 being very strong impact).

Part A: Amount of support you provide / Part B: Impact this has on you
No support / Some Support / Full Support / I can’t / don’t want to continue providing this / 1 / 2 / 3 / 4 / 5
Washing face
and hands /  / and / 
Using bath/shower or washing all over /  / and / 
Part A: Amount of support you provide / Part B: Impact this has on you
No support / Some Support / Full Support / I can’t / don’t want to continue providing this / 1 / 2 / 3 / 4 / 5
Washing face
and hands / and
Using bath/shower or washing all over / and
Dressing / and
Getting in or
out of bed / and
Assisting to the toilet / and
Meal preparation / and
Supervision of eating drinking / and
Shopping / and
Laundry / and
Housework / and
Correspondence and paperwork / and
Part A: Amount of support you provide / Part B: Impact this has on you
No support / Some Support / Full Support / I can’t / don’t want to continue providing this / 1 / 2 / 3 / 4 / 5
Driving / arranging transport / and
Escorting to keep in touch with family and friends / and
Escorting to use community facilities e.g. library or place of worship / and
Making sure
they are safe / and
Dealing with crises / and
Helping them to take medicines / and
Supporting them emotionally / and
Organising appointments/visits e.g. with GPs, Social Services / and
Managing finances for the person you care for / and

Section D: The impact your caring role has on you

In this section please select the option that best describes how often each area of your life is affected by your caring role (Part A) and then the impact this has on you (Part B).

For Part B tick the box using the following scale of 1 to 5 (1 being no impact – 5 being very strong impact).

Part A: How often your caring roles affect you / Part B: Impact this has on you
No affect / not applicable to me / It affects me sometimes / It affects me all the time / It affects me so much that I can’t / don’t want to continue doing this / 1 / 2 / 3 / 4 / 5
Time for Me /  / and / 
Part A: How often your caring role affects you / Part B: Impact this has on you
No affect / not applicable to me / It affects me sometimes / It affects me all the time / It affects me so much that I can’t / don’t want to continue doing this / 1 / 2 / 3 / 4 / 5
Time for Me / and
Mental / Emotional wellbeing / and
Physical wellbeing / and
Health / and
Education / Training / and
Leisure time / and
Relationships / and
Employment / Volunteering / and
Financial / and

Thank you for completing this self assessment questionnaire.

Where you have indicated some interest in the services provided, you can either call the service direct or we can help you make contact. Carers may be entitled to financial support (a personal budget) if they care for someone who is receiving support from Social Services or who is eligible for a personal budget.

1Carers SAQ June 2010