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?