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North Lincolnshire Council
Section 1

Carers Self Assessment

This is a self-assessment form for carers of adults to complete. The information and comments provided will help Adult Social Care Services to identify your needs as a carer and also how the service can help and support you to continue providing care for the person you look after.

A simple definition of a Carer is:

“A Carer is a person who offers substantial and regular care to someone, who without it could not manage their daily living.”

Please complete all relevant sections.
 

Carer's Personal Details

Your Full Name
 
 
Usual Address
 

 

To use the address function within this application, your address MUST be within the North Lincolnshire boundary. To check this is the case, please enter your Postcode in the box below and select 'find address'. If you live outside North Lincolnshire you can still apply using this form but you will need to complete your address in full.
 
 
 
If you have provided a valid email address you will automatically receive a copy of your completed form when submitted.
 
Date of Birth *
Date of Birth
 
 
 
 
Ethnicity:
Ethnicity:
 
White
White
Mixed
Mixed
Black or Black British
Black or Black British
Asian or Asian Background
Asian or Asian Background
Chinese or other ethnic group
Chinese or other ethnic group
 
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