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

Title

If Other, please specify

First name(s) *

Surname *

Usual Address

If the address is within North Lincolnshire, enter the postcode in the box below and then select "find address". If the address is outside of North Lincolnshire, or your address is NOT SHOWN in the list or is incorrect, you will need to enter the address in the boxes provided below.

Postcode *

Prefix

e.g. first floor flat

House number/name *

Street *

Town/village

County

Country

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

NHS Number (if known) Help Icon

Please enter with no spaces (e.g. 1234567890)

Relationship to the person they care for *

White

British

Irish

Other white background (see below)

If other please specify

Mixed

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background (see below)

If other please specify

Black or Black British

Caribbean

African

Any other black background (see below)

If other please specify

Asian or Asian Background

Indian

Pakistani

Bangladeshi

Any other asian background (see below)

If other please specify

Chinese or other ethnic group

Chinese

Other ethnic group (see below)

If other please specify

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