Carers self assessment
It would be helpful for you to have your NHS number to hand as we will need this information. We will contact you on your preferred method to discuss your assessment and if necessary, arrange a face-to-face visit to help you plan your support.
To help us get a better idea of your current situation, please answer all questions. Your answers will help us to provide you with the right information, advice or support to help keep you well in your caring role, so please give us as much detail as you can.
When completing your assessment, think about your life, what you enjoy and would like to achieve, and the effect that your caring role has on you and your family.
Are we your local authority?
If you are a carer, the person who you care for needs to live within the boundary of Solihull to receive support services from us.
Mandatory - Does the person you care for live in Solihull?
If the person you care for does not live in Solihull, please contact the local authority listed at GOV.UK
If you are completing this assessment on behalf of someone else
If you are completing this assessment on behalf of someone else, please answer each question as if you were them. You will need to gain permission from the person before completing this assessment. If the person declines consent and you have concerns, please call 0121 704 8007 to discuss.
If the person you care for is not receiving services from Solihull Adult Social Care, your assessment will be re-directed to the Carers Trust, who will contact you to finalise your assessment.
You need the person's permission before completing the assessment. If the person does not consent and you have concerns, please call us on 0121 704 8007.
Your details
Invalid - Email
Who is this assessment for
Mandatory - First name
Mandatory - Last name
Invalid Date - Date of birth (e.g. 01/05/1950)Mandatory - Date of birth (e.g. 01/05/1950)
Mandatory - House number or name
Mandatory - Postcode
Mandatory - Email
Mandatory - Telephone
Mandatory - NHS Number
Your assessment
Mandatory - Have you previously completed a carer's assessment?
If you answered ‘No’, a carers review may be more suitable. We will contact you when your carers’ review is due. If you wish to discuss your review, please call us on 0121 704 8007.
Mandatory - What is your main reason for contacting us?
Mandatory - How many adults do you provide unpaid care to?
Mandatory - What is their relationship to you?
Mandatory - Are they receiving care and support services through Solihull Council?
Mandatory - Do they live in the same home as you?
Mandatory - Do they receive any other support paid or unpaid?
Mandatory - On average, how many hours a week do you provide care?
What support do you provide as follows:
Tell us more about you
Mandatory - Your journey to being a carer, your interests and hobbies, what do you do to relax, your career before and during caring?
Mandatory - Do you have difficulty communicating with others?
Mandatory - Is your GP aware that you are a carer?
It would be beneficial for you to advise your GP, as this may open other avenues of support.
Mandatory - Are you registered as a carer with the Department for Works and Pensions?
You may be entitled to Carer's Allowance, visit www.gov.uk/carers-allowance to find out more. This benefit is separate from Adult Social Care and will not affect this assessment.
Caring role
Mandatory - What areas of your caring role are going well now?
Mandatory - What support do you have in your life e.g family, friends, neighbours, Age UK, Community hub, Solihull Mind, Carers Trust, other professionals?
Carer needs
Think about your caring role specifically and if the following areas are directly affected by caring.
Mandatory - Do you care for a child, including grandchildren or stepchildren?
Mandatory - Does your caring responsibility for each adult you have named affect the care you provide to any other adults you mentioned?
Mandatory - Is your home safe and do you have all essential amenities (such as heating and water)? Are you able to pay your household bills and deal with the maintenance of your home?
Mandatory - Can you manage food shopping and preparing your meals for you and your family?
Mandatory - Does your caring role affect your relationship with family and friends?
Mandatory - Are you able to take part in work, training, education or volunteering as much as you want to?
Mandatory - Do you have time for yourself, to take part in activities or hobbies alongside your caring role?
Mandatory - Are you able to use local services and facilities in your community (for example, public transport, the library, bank, social groups etc.)
Mandatory - Looking at each answer you gave in the Carer needs section, please tell us how each one affects your caring role?
Mandatory - What do you feel would improve things for you?
Contact person
Mandatory - Who do you want us to contact about this assessment?
Mandatory - How do you want us to contact you (phone, email, video call etc)?
Submit
To complete this form you must acknowledge and agree to the following:
- I confirm that the information I have provided in this assessment is true
- I understand that any support from Adult Social Care may change if the information in this assessment is incorrect or my situation changes
- I understand that a computer record will be made which will be treated confidentially by Solihull Council. This information is held by the Council for the purpose of providing information, advice and support to meet my needs
- I understand that the Council will share information about me where appropriate with relevant NHS agencies and provider of care and support services which will help to reduce the number of times I am asked for the same information
- I understand that the information on this form will only be shared as allowed by the Data Protection Act 2018 and the General Data Protection Regulations
- I confirm that if I have completed this assessment on behalf of somebody else, I have gained consent from this person
For further information about how we use your information, please refer to our Privacy Statement or email ccadults@solihull.gov.uk.
Mandatory - I agree
Data Protection
Your information may be shared with other council services and partner organisations to ensure
our records are kept accurate and to help us to identify services or benefits you may be entitled to or interested in.
We may also need to share your information for the prevention and detection of fraud and/or other crimes or as the law requires.
For further information about how we use your information please refer to the Council’s Privacy Statement on
www.solihull.gov.uk.