Carer's Self-Assessment

Carer's Self-Assessment
Please complete all of the questions below to the best of your ability. Following the submission of your completed form we will contact you to discuss your support options and how we can best assist you in your caring role.

If you would like to discuss any of the questions further before submitting your form, please contact us on 0345 688 7113 (Monday - Friday 9am-5pm) or email enquiries@lancscarers.co.uk
Personal Details
Title*

MrMrsMissMsDrOther
Date of assessment*

DayMonthYear
First name*
Surname*
Date of birth*

DayMonthYear
Current age*
Gender*

FemaleMalePrefer not to sayOther
Telephone number*
Please provide details below of convenient days and times so we are able to contact you to discuss the options of support that are available to you as a Carer (Monday - Friday 9am - 5pm) N.B. If you are a working Carer and are not able to be contacted during these times, we are able to consider an evening appointment Monday - Thursday where required.*
Address*
Email address*
example@example.com
Preferred language*
1. Do you need an interpreter?*

YesNoMaybe
2. Do you consider yourself to be any of the following?*

BlindDeafBothNo
3. Do you have communication difficulties?*

YesNo
3a. If yes, please provide further details
4. Do you have any difficulties with understanding and/or retaining information?*

YesNoMaybe
4a. If yes, please write details of any difficulties and their impact
5. Do you have any difficulties making decisions and/or understanding their impact?*

YesNoMaybe
5a. If yes, please write details of difficulties and what would help you communicate more easily during your assessment
6. Are there any other people involved in your assessment? (e.g. advocate, family, friend, other professionals)*

YesNoMaybe
6a. If yes, please include names, roles/relationship and contact details
7. Have you or the person you care for ever engaged in military service including service within the territorial army?*

YesNo
8. Your personal and family background (e.g., a little bit of information about you, your home situation, family life, work commitments, who you care for, the condition/s of the person you care for, recent life events currently impacting on you/your caring role and also please include any other information you feel is relevant)*
9. What areas of your life do you most enjoy and value? (e.g. hobbies or interests)*
10. What changes would most improve your wellbeing or quality of life?*
11. What aspects of your caring role do you think are the most important, valuable and positive?

Keeping the person I care for safeMaintaining the independence of the person I care forKeeping the person I care for happyOther
12. Do you live with the person you care for?*

YesNo
12a. If no, do you have difficulties getting to the person if so please specify difficulties
12b. If yes, please explain what the difficulties are and what you would like to achieve
13. Are you experiencing any financial difficulties?*

YesNo
14. Have you or the person you care for had a benefit check?*

YesNo
14a. If no, would you like to be contacted about a benefit check?

YesNo
15. Does your caring role have an impact on you being able to maintain a clean and safe home environment?*

No, not at allYes, low impactYes, significant impactYes, major impact
15a. If yes, please explain what the difficulties are and what you would like to achieve
16. Does your caring role impact on you being able to shop for and prepare adequate meals for yourself?*

No, not at allYes, low impactYes, significant impactYes, major impact
16a. If yes, please state what the difficulties are and what would you like to achieve?
17. Does your caring role impact on your ability to maintain contact with people important to you? (e.g. friends, family, etc.)*

No, not at allYes, low impactYes, significant impactYes, major impact
17a. If yes, please state what the difficulties are and what would you like to achieve?
18. Does your caring role impact on your ability to get out into the community and/or engage in community activities?*

No, not at allYes, low impactYes, significant impactYes, major impact
18a. If yes, please state what the difficulties are and what would you like to achieve?
19. Please select the below options which are applicable to you*

I am in paid employmentI am in voluntary workI am a full-time unpaid CarerI am retiredOther
20. Does your caring role impact on your involvement with work, training, education or volunteering?*

No, not at allYes, low impactYes, significant impactYes, major impact
20a. If yes, please state what the difficulties are and what would you like to achieve?
21. How would you describe your current emotional wellbeing?*

I'm calm and unstressedI'm under occasional stressI'm under regular stressI'm regularly highly stressed
22. What is the risk of your mental health deteriorating due to your caring role?*

No riskLow riskSignificant riskSerious risk
23. How would you describe your current physical health/wellbeing?*

I'm in generally good healthI'm in reasonable healthI'm in fairly poor healthI'm in very poor health/ terminally ill
24. What is the risk of your physical health deteriorating due to your caring role?*

No riskLow riskSignificant riskSerious risk
25. Have you ever felt distressed or in danger due to the behaviour of the person you care for?*

YesNo
25a. Please provide additional details below or alternatively you can discuss any concerns you may have during the call to discuss your support options.
26. Do you have any children that are dependent on you?*

YesNo
27. Do you have caring responsibilities for another adult?*

YesNo
28. Do you have difficulties with assisting the person you care for to move around?*

YesNo
28a. If yes, please provide further details below
29. Do you share your caring role with another family member or friend?*

YesNo
29a. If yes, are any of the Carer(s) under the age of 18?

YesNo
30. How much support do you gain from others?*

NoneA lot of supportA little regular supportA substantial amount of supportOccasional support only
31. Does your GP know you are a Carer?*

YesNo
32. If you are ill or unavailable to provide care, are there alternative arrangements in place?*

YesNo
32a. If yes, what are the arrangements?
33. Are you able to continue in your caring role?*

YesNo
34. Are you willing to continue in your caring role?*

YesNo
35. Do you have any concerns about the longer-term future? If yes, what are they?
36. Please tick which areas you currently provide support with*

Housework / laundryManaging paperwork / financesPreparing meals / snacks / drinks and / or helping to eat and drinkShopping for food / essential itemsEmotional supportSupporting with medicationMoving and handlingEnsuring safety during the dayEnsuring safety during the night timeEscorting person / proving transportHelp communicate with othersProviding companyHelp caring for childrenOther
37. How often are you able and willing to continue providing this support? Please enter number of days and times of the day e.g. 5 mornings, 2 afternoons and 3 evenings per week.*
38. Is the person you care for aware that you are having an assessment?*

YesNo
39. Has the person you care for had their own needs assessment?*

YesNo
40. What is the cared for persons relation to you?*

Family memberNeighbourFriendOther
41. What is the longest period you regularly leave the person you care for alone?*

30 minutes1-2 hours2-3 hours3-4 hoursAll dayDuring the nightI can't, they need 24-hour care
42. Please choose a statement below to best describe the needs of the person you care for*

The cared for is able to manage well in all areas as there are no significant physical or mental health issues.The cared for needs a small amount of weekly support as there are some minor physical / mental health issues or social difficulties, but they can manage alone more than one day at a time.The cared for needs a small amount of daily support with one or two physical tasks and/or requires regular support to avoid low mood loneliness or harm. They need checking most days or daily to stay safe.The cared for needs support more than once a day with a number of physical tasks and/or requires significant support to avoid low mood, loneliness or risk of harm. They can be left alone for extended periods but needs more support more than once a day to be safe.The cared for needs support with most physical tasks and/or has mental health issues or social/learning difficulties which make it difficult to manage day-to-day life. They can only be left alone for up to 2-3 hours and/or needs checking at night but doesn't need someone present all the time.The cared for has difficulties in many/most areas and needs someone present all the time or nearly all the time to stay safe during the day and during the night but does not need 24 hour support.The cared for cannot be safely left alone during the day or at night, needing high level of 24-hour support. They may need specialist care and support and/or may need the support of more than one carer.
43. One of our team will review your assessment and contact you to discuss the support options available to you as a Carer. Thank you for taking the time to complete this form. If you would like to provide any further information you feel is relevant, please add details of this below:
Source
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Carer's Self-Assessment

Personal Details