All support provided by The Carers’ Support Service is free and confidential.

We will contact you within 5 working days of receiving your form. Please note, we will need to contact you to complete your registration with us.

* 1. Your Contact Details (please complete all fields)

Title
Full Name
Address
Town
Post Code
Date of Birth
Phone Number
Email Address
GP and/or GP Surgery

2. The person you care for (Please complete all fields)

Full Name
Date of Birth
Address (if different from yours)
Town
Post Code
Their relationship to you (mother, brother, etc.)
Their disability/medical condition
GP and/or GP Surgery

* 3. Please tell us a bit about the care you provide. Please tick all options that apply. I support with: (If you care for a child with additional needs, please consider what support you provide that is in addition to support you would provide to a child with no additional needs)

Personal Care (Hygiene)Personal Care (Toileting)Preparing/Cooking mealsTaking to/Arranging social activities and appointmentsManaging medicationFinance and communications (paying bills and writing letters/making phone calls)Emotional SupportDomestic Duties/GardeningGrocery ShoppingSupport through the nightManaging behaviourMoving and handling (Mobility and moving about)The person I care for cannot be left alone

Other (please tell us about any other support you provide)

* 4. Where did you hear about us?