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Register with Wandsworth Carers
Fill out our quick and easy registration form below
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Thank you for your interest in Wandsworth Carers’ Centre and Carers Partnership Wandsworth. We provide information and support to all unpaid Carers over the age of 16yrs who either live in the borough of Wandsworth, have a GP in Wandsworth or care for someone who lives in the borough of Wandsworth. To enable you to use the services of the partnership, we require you to register with us.
Information about the carer
Are you the carer completing this registration?
*
Yes
No
What support do you currently require?
*
To be eligible for our services you must have a link with the borough of Wandsworth. Do you or the person you Care for live in Wandsworth?
*
Yes
No
Title (please write in) (e.g. Ms, Mr, Miss, Mx)
Full name of carer
Date of birth
*
Full address of carer
*
Post code
*
Email address
*
Contact number
*
Emergency contact name
*
Emergency contact number
*
Relationship of emergency contact to carer
Employment Status
*
Unemployed
Employed Full Time
Employed Part Time
In Education or Training
GP Name and Surgery
Does your GP know you are a Carer?
*
Yes
No
If no, would you like us to inform them for you?
Yes
No
Is there anyone under 18 years old living with the person cared for?
*
Yes
No
How did you hear about us?
*
Information about the person Cared for
*
First name
Last name
*
Last name
Date of Birth
*
Address if different to Carer
*
Street Address
Postcode
*
Relationship to Carer
*
GP name and Surgery of cared for person
*
Health condition and support needs
*
Autistic spectrum disorder
Dementia
Learning disability
Mental health
Multiple disabilities
Older person
Physical disability
Physical illness
Substance misuse
Other
If health condition is Other please provide details below?
What type of care does the carer provide?
*
Personal care. i.e. washing and dressing
Practical: i.e. assisting with medication, cooking, shopping, advocacy
Emotional: i.e. listening and reassuring
More information on your caring role
Please tell us a bit more about the type of care you provide.
Hours of care provided
*
0-9hrs
10-19hrs
20-34hrs
35-49hrs
50+hrs
Please indicate how you are feeling with the following:
Your health
*
As good as it can be
I'm finding what works for me
I'm making changes in this area
I'm getting help with this
This is a cause for concern
Your caring role
*
As good as it can be
I'm finding what works for me
I'm making changes in this area
I'm getting help with this
This is a cause for concern
Your employment
*
As good as it can be
I'm finding what works for me
I'm making changes in this area
I'm getting help with this
This is a cause for concern
Managing at home
*
As good as it can be
I'm finding what works for me
I'm making changes in this area
I'm getting help with this
This is a cause for concern
Your finances
*
As good as it can be
I'm finding what works for me
I'm making changes in this area
I'm getting help with this
This is a cause for concern
Having time for yourself
*
As good as it can be
I'm finding what works for me
I'm making changes in this area
I'm getting help with this
This is a cause for concern
Your emotional wellbeing
*
As good as it can be
I'm finding what works for me
I'm making changes in this area
I'm getting help with this
This is a cause for concern
Which of our services would you like to access?
Please check all the services you would like to access
Services
*
Select All
Newsletter
Training and workshops
Counselling
Information and advice
Respite
One to one support and advocacy
Peer support i.e. Groups, activities and trips
Back care and therapies
Benefits advice
Other
Please tick to confirm you have read and understood Wandsworth Carers’ Centre’s
privacy policy
and give permission for my information to be stored on Wandsworth Carers’ Centre’s database. I also give permission for Wandsworth Carers’ Centre to contact me by phone, email, post.
Privacy policy
By signing this form you are giving Wandsworth Carers’ Centre permission to securely store your information on their database and to contact you regarding your Caring role.
Wandsworth Carers’ Centre has a legal duty to disclose safeguarding concerns where we have information that a person is a risk either to themselves or another person.
I have understood the above statement
Confidentiality
*
Wandsworth Carers’ Centre has a legal duty to disclose safeguarding concerns where we have information that a person is a risk either to themselves or another person.
I have read and understood the above statement.
Wandsworth Carers’ Centre is registered with Recognising Excellence to ensure the advice we give you is of a high standard and meets the Advice Quality Standards (AQS). Please let us know if you give permission for Recognising Excellence to assess the advice you receive from us.
Wandsworth Carers’ Centre is registered with Recognising Excellence to ensure the advice we give you is of a high standard and meets the Advice Quality Standards (AQS).
Please let us know if you give permission for Recognising Excellence to assess the advice you receive from us.
I give permission for Recognising Excellence to assess advice given to me by Wandsworth Carers’ Centre
Signature
Consent
Verbal / Email Consent given by Carer:
Staff Name
First
Last
Staff Signature
Equality & Diversity Form for Carer
Ethnicity of Carer
*
What do you consider to be your Ethnic Origin?
Asian or Asian British: Bangladeshi
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Other
Black or Black British: Black African
Black or Black British: Black Caribbean
Black or Black British: Other
Chinese or other ethnic group: Chinese
Chinese or other ethnic group: Other
Mixed: Other
Mixed: White and Asian
Mixed: White and Black African
White and Black Caribbean
Other
Unspecified
White: British
White: Irish
White: Other
Traveller
Gypsy/Romany
I prefer not to answer
Health Condition of Carer
*
Do you consider yourself to have a disability?
Yes
No
I prefer not to answer
If yes, please tick the relevant box/boxes below:
Physical impairment
Sensory impairment
Long-term condition
Mental Health condition
Learning disability/difficulty
Other health condition (please specify)
Sexual Orientation
*
Which of the following options best describes you? LGBT+ Get support here - Email: Tom@wandsworthcarers.org.uk
Heterosexual/straight
Lesbian/Gay
Bisexual
I prefer not to answer
I identify in a way not given above (e.g. pansexual, asexual, questioning) / I self-identify (use my description):
Gender Identity
*
Which of the following best describes your gender identity?
Man/Male (including trans men)
Woman/Female (including trans women)
Non-binary
I prefer not to answer
I identify in another way (e.g. gender fluid, agender, questioning)/ use my own description:
Trans Status Monitoring
*
Is your gender identity the same as the gender you were given at birth?
Yes
No
I Prefer not to answer
Pronouns
*
Please use the following pronouns to describe me:
He/Him
She/Her
They/Them
No pronouns
I Prefer not to answer
If your pronouns have not been listed above, please write in space. My pronouns are:
Religion
*
Christianity
Catholicism
Judaism
Hinduism
Buddhism
Islam
Sikhism
None / No formal religion
I prefer not to answer
Other
Other religion (please specify)
Please note, you can opt out of text or emails at any time by contacting Wandsworth Carers’ Centre or by responding to any text or email you receive from us.
Consent
I agree to the privacy policy.
Untitled
Untitled
First Choice
Second Choice
Third Choice
Phone
This field is for validation purposes and should be left unchanged.
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